Type 2 Diabetes Management PDF

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Guideline Summary NGC-7360

Guideline Title
Diagnosis and management of type 2 diabetes mellitus in adults.
Bibliographic Source(s)
Institute for Clinical Systems Improvement (ICSI). Diagnosis and management of type 2 diabetes mellitus in adults.
Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2009 May. 114 p. [168 references]
Guideline Status
Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this
summary.
FDA Warning/Regulatory Alert
Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised
regulatory and/or warning information has been released.
: The U.S. Food and Drug Administration (FDA) notified healthcare
March 12, 2010 - Plavix (clopidogrel)
professionals and patients that a Boxed Warning has been added to the prescribing information for Plavix, an antiblood clotting medication. The Boxed Warning includes information about reduced effectiveness in patients who are
poor metabolizers of Plavix.
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: The U.S. Food and Drug Administration (FDA) notified healthcare

November 17, 2009 - Plavix (clopidogrel)
professionals of new safety information concerning an interaction between clopidogrel (Plavix) and omeprazole
(Prilosec/Prilosec OTC) used to reduce stomach acid. New data show that when clopidogrel and omeprazole are taken
together, the effectiveness of clopidogrel is reduced.
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Scope
Disease/Condition(s)
l Prediabetes
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Type2diabetesmellitus
Note: The diagnosis of gestational diabetes or the management of diabetes in patients who are pregnant is excluded from the scope of this
guideline. Also, the diagnosis and management of type 1 diabetes is not included in this guideline.
Guideline Category
Counseling
Diagnosis
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Cardiology
Endocrinology
Family Practice
Internal Medicine
Nephrology
Neurology
Nutrition
Ophthalmology
Podiatry
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Ophthalmology
Podiatry
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Physician Assistants
Physicians
Podiatrists
Guideline Objective(s)
Toprovideacomprehensiveapproachtothediagnosisandmanagementofprediabetesandtype2diabetes
mellitus in adults age 18 and older. Management will include nutrition therapy, physical activity, self-management
strategies, and pharmacologic therapy recommendations, as well as prevention and diagnosis of diabetes-associated
complications and risk factors
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Tomaximizethepercentageofadultpatients,ages18to75withtype2diabetesmellitus,whoinadefined
period of time achieve any of the possible measures of established control
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Tomaximizethepercentageofadultpatientsages18to75withtype2diabetesmellitus,whoinaone-year
period of time achieved the identified measures of care
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Tomaximizethepercentageofadultpatientsages18to75withtype2diabetesmellitusforwhomrecommended
screening procedures are done
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Toidentifyandfocusonahigherriskpopulationbydecreasingthepercentageofadultpatients,ages18to75
with type 2 diabetes mellitus, with poorly controlled glucose and cardiovascular risk factors (clinical strategies that
target high-risk populations may be more viable with limited resources)
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Target Population
Adult patients age 18 and over with prediabetes or type 2 diabetes mellitus
Interventions and Practices Considered
Prevention
1.Laboratorytestsincludingimpairedfastingglucoseorimpairedglucosetolerance
2.Patienteducationincludinglifestylebehaviorchanges,nutritioncounseling,andcardiovascularriskreduction
3.Monitoringandfollow-up testing as indicated
4.Pharmacologic therapy including biguanides, alpha glucosidase inhibitors, angiotensin-converting enzyme (ACE)
inhibitors, and thiazolidinediones.
Diagnosis
Detailed medical history, physical examination and confirmatory laboratory testing (refer to "Major Recommendations"
section)
Treatment/Management
1.Pharmacologictherapyincluding:
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Glycemicmanagement,includinginsulintherapy,non-insulinagents,andcombinations
Bloodpressurecontrol,includingangiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor

blockers (ARBs), thiazide diuretic
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Statins
2.Educationandself-management, including:
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Nutritiontherapyprogram
Physicalactivityprogram(precededbymedicalassessmentofphysicalconditions,limitations,riskof
cardiovascular disease, cardiac stress testing and blood glucose control)
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Weightmanagement
Footcare
Communityresources
3.Othermeasurestoreducecardiovascularrisk:aspirinuse,tobaccocessation
4.Ongoingassessmentforcomplicationstreatmentand/orreferralforcomplicationsasappropriate
Major Outcomes Considered
Morbidity and mortality associated with type 2 diabetes mellitus and/or complications
Weightmanagement
Footcare
Communityresources
3.Othermeasurestoreducecardiovascularrisk:aspirinuse,tobaccocessation
4.Ongoingassessmentforcomplicationstreatmentand/orreferralforcomplicationsasappropriate
Major Outcomes Considered
Morbidity and mortality associated with type 2 diabetes mellitus and/or complications
Methodology
Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
A literature search of clinical trials, meta-analysis, and systematic reviews is performed.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Key conclusions (as determined by the work group) are supported by a conclusion grading worksheet that summarizes
the important studies pertaining to the conclusion. Individual studies are classed according to the system presented
below, and are designated as positive, negative, or neutral to reflect the study quality.
Conclusion Grades:
Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The
results are both clinically important and consistent with minor exceptions at most. The results are free of any
significant doubts about generalizability, bias, and flaws in research design. Studies with negative results have
sufficiently large samples to have adequate statistical power.
Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but
there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or
because of minor doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively,
the evidence consists solely of results from weaker designs for the question addressed, but the results have been
confirmed in separate studies and are consistent with minor exceptions at most.
Grade III: The evidence consists of results from studies of strong design for answering the question addressed, but
there is substantial uncertainty attached to the conclusion because of inconsistencies among the results of different
studies or because of serious doubts about generalizability, bias, research design flaws, or adequacy of sample size.
Alternatively, the evidence consists solely of results from a limited number of studies of weak design for answering the
question addressed.
Grade Not Assignable: There is no evidence available that directly supports or refutes the conclusion.
Study Quality Designations
The quality of the primary research reports and systematic reviews are designated in the following ways on the
conclusion grading worksheets:
Positive: indicates that the report or review has clearly addressed issues of inclusion/exclusion, bias, generalizability,
and data collection and analysis.
Negative: indicates that these issues (inclusion/exclusion, bias, generalizability, and data collection and analysis)
have not been adequately addressed.
Neutral: indicates that the report or review is neither exceptionally strong nor exceptionally weak.
Not Applicable: indicates that the report is not a primary reference or a systematic review and therefore the quality
has not been assessed.
Classes of Research Reports:
A.PrimaryReportsofNewDataCollection:
Class A:
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Randomized,controlledtrial
Class B:
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Cohortstudy
Class C:
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Nonrandomizedtrialwithconcurrentorhistoricalcontrols
Case-control study
Studyofsensitivityandspecificityofadiagnostictest
Population-based descriptive study
Class D:
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Cross-sectional study
Caseseries
Casereport
Case-control study
Class D:
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Caseseries
Casereport
B.ReportsthatSynthesizeorReflectuponCollectionsofPrimaryReports:
Class M:
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Meta-analysis
Systematicreview
Decisionanalysis
Cost-effectiveness analysis
Class R:
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Consensusstatement
Consensusreport
Narrativereview
Class X:
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Medicalopinion
Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
New Guideline Development Process
A new guideline, order set, and protocol is developed by a 6- to 12-member work group that includes physicians,
nurses, pharmacists, other healthcare professionals relevant to the topic, along with an Institute for Clinical Systems
Improvement (ICSI) staff facilitator. Ordinarily, one of the physicians will be the leader. Most work group members are
recruited from ICSI member organizations, but if there is expertise not represented by ICSI members, 1 or 2 members
may be recruited from medical groups or hospitals outside of ICSI.
The work group will meet for seven to eight three-hour meetings to develop the guideline. A literature search and
review is performed and the work group members, under the coordination of the ICSI staff facilitator, develop the
algorithm and write the annotations and footnotes and literature citations.
Once the final draft copy of the guideline is developed, the guideline goes to the ICSI members for critical review.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
The guideline developers reviewed published cost analyses.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
Critical Review Process
Every newly developed guideline or a guideline with significant change is sent to Institute for Clinical Systems
Improvement (ICSI) members for Critical Review. The purpose of critical review is to provide an opportunity for the
clinicians in the member groups to review the science behind the recommendations and focus on the content of the
guideline. Critical review also provides an opportunity for clinicians in each group to come to consensus on feedback
they wish to give the work group and to consider changes necessary across systems in their organization to implement
the guideline.
All member organizations are expected to respond to critical review guidelines. Critical review of guidelines is a
criterion for continued membership within the ICSI.
After the critical review period, the guideline work group reconvenes to review the comments and make changes, as
appropriate. The work group prepares a written response to all comments.
Approval
Each guideline, order set, and protocol is approved by the appropriate steering committee. There is one steering
committee each for Respiratory, Cardiovascular, Women's Health, and Preventive Services. The Committee for
Evidence-based Practice approves guidelines, order sets, and protocols not associated with a particular category. The
steering committees review and approve each guideline based on the following:
All member organizations are expected to respond to critical review guidelines. Critical review of guidelines is a
criterion for continued membership within the ICSI.
After the critical review period, the guideline work group reconvenes to review the comments and make changes, as
Approval
Each guideline, order set, and protocol is approved by the appropriate steering committee. There is one steering
committee each for Respiratory, Cardiovascular, Women's Health, and Preventive Services. The Committee for
Evidence-based Practice approves guidelines, order sets, and protocols not associated with a particular category. The
steering committees review and approve each guideline based on the following:
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Membercommentshavebeenaddressedreasonably.
ThereisconsensusamongallICSImemberorganizationsonthecontentofthedocument.
Withintheknowledgeofthereviewer,thescientificrecommendationswithinthedocumentarecurrent.
Eitheracriticalreviewhasbeencarriedout,ortotheextentoftheknowledgeofthereviewer,thechanges
proposed are sufficiently familiar and sufficiently agreed upon by the users that a new round of critical review is not
needed.
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Once the guideline, order set, or protocol has been approved, it is posted on the ICSI Web site and released to
members for use. Guidelines, order sets, and protocols are reviewed regularly and revised, if warranted.
Document Revision Process
ICSI scientific documents are revised every 12 36 months as indicated by changes in clinical practice and literature.
Every 6 months, ICSI checks with the work group to determine if there have been changes in the literature significant
enough to cause the document to be revised earlier than scheduled.
Prior to the work group convening to revise the document, ICSI members are asked to review the document and submit
comments. During revision, a literature search of clinical trials, meta-analysis, and systematic reviews is performed and
reviewed by the work group. The work group will meet for 1-2 three-hour meetings to review the literature, respond to
member organization comments, and revise the document as appropriate.
If there are changes or additions to the document that would be unfamiliar or unacceptable to member organizations, it
is sent to members to review prior to going to the appropriate steering committee for approval.
Review and Comment Process:
ICSI members are asked to review and submit comments for every guideline, order set, and protocol prior to the work
group convening to revise the document.
The purpose of the Review and Comment process is to provide an opportunity for the clinicians in the member groups
to review the science behind the recommendations and focus on the content of the order set and protocol. Review and
Comment also provides an opportunity for clinicians in each group to come to consensus on feedback they wish to give
the work group and to consider changes needed across systems in their organization to implement the guideline.
All member organizations are encouraged to provide feedback on order sets and protocol; however, responding to
Review and Comment is not a criterion for continued membership within ICSI.
After the Review and Comment period, the work group reconvenes to review the comments and make changes as
Recommendations
Major Recommendations
summary. The recommendations that follow are based on the previous version of the guideline.
Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement
(ICSI): For a description of what has changed since the previous version of this guidance, refer to Summary of
Changes Report -- May 2009
The recommendations for the management of type 2 diabetes mellitus are presented in the form of 4 algorithms with a
total of 38 components, accompanied by detailed annotations. Algorithms are provided for: Diagnosis and Management
of Type 2 Diabetes Mellitus, Glycemic Control, Blood Pressure Control, and Ongoing Management; clinical highlights and
selected annotations (numbered to correspond with the algorithm) follow.
Class of evidence (A-D, M, R, X) and conclusion grade (I-III, Not Assignable) definitions are repeated at the end of the
"Major Recommendations" field.
Clinical Highlights
Educationandself-management support is necessary for people with diabetes to manage their disease.
(Annotation #10)
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Focusoncardiovascularriskreduction(bloodpressurecontrol,low-density lipoprotein cholesterol control and

statin use, aspirin use and tobacco cessation). (Annotations #11, 13, 14)
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Glycosylatedhemoglobin(A1c)levelsshouldbeindividualizedtothepatient.(Annotations #11)
Aggressivebloodpressurecontrolisjustasimportantasglycemiccontrol.Systolicbloodpressurelevelshouldbe
the major factor for detection, evaluation, and treatment of hypertension. The use of two or more blood pressure
lowering agents is often required to meet blood pressure goal. (Annotations #13, 14 )
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Preventmicrovascularcomplicationsthroughannualorbiannualeyeexams,footriskassessmentsandfootcare
counseling, and annual screening for proteinuria. (Annotations # 35)
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Initialtherapywithlifestyletreatmentandmetforminisadvisedunlesscontraindicated. (Annotations #4, 10)
Diagnosis and Management of Type 2 Diabetes Mellitus Algorithm Annotations

1.Diagnostic Testing for Diabetes
Prediabetes is now the term recommended for patients with impaired glucose tolerance or impaired fasting glucose.
Type 2 diabetes is frequently not diagnosed until complications appear, and approximately one-third of all people
with diabetes may be undiagnosed [R].
Preventmicrovascularcomplicationsthroughannualorbiannualeyeexams,footriskassessmentsandfootcare
counseling, and annual screening for proteinuria. (Annotations # 35)
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Initialtherapywithlifestyletreatmentandmetforminisadvisedunlesscontraindicated. (Annotations #4, 10)
Diagnosis and Management of Type 2 Diabetes Mellitus Algorithm Annotations

1.Diagnostic Testing for Diabetes
Prediabetes is now the term recommended for patients with impaired glucose tolerance or impaired fasting glucose.
Type 2 diabetes is frequently not diagnosed until complications appear, and approximately one-third of all people
with diabetes may be undiagnosed [R].
Possible tests to assess for diabetes include a fasting plasma glucose or an oral glucose tolerance test. A fasting
blood glucose is the preferred test for screening for diabetes [R].
Patients presenting with symptoms of diabetes should be tested.
Risk factors for diabetes include:
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Riskfactorsforatherosclerosis:smoking,hypertension,dyslipidemia.
Age,race/ethnicity,familyhistoryofdiabetes,priorhistoryofdiabetes,physicalinactivity,cardiovascular
disease, cerebral vascular disease, hyperlipidemia, overweight/obese (as defined by body mass index), low highdensity lipoprotein, high triglycerides, polycystic ovarian syndrome.
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Gestationhistoryofaninfantweighingmorethanninepounds,toxemia,stillbirthorpreviousdiagnosisof
gestational diabetes.
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Testing patients with hypertension, blood pressure over 130/80, dyslipidemia or heart disease is also
recommended.
See the NGC summaries of the ICSI guidelines: Hypertension Diagnosis and Treatment, Lipid Management in
Adults, the Preventive Services for Adults, the Prevention and Management of Obesity (Mature Adolescents and
Adults) and the Stable Coronary Artery Disease for more information.
2.Evaluation of Patients with Elevated Glucose
Evaluation may be completed in one or more visits over a reasonably short period of time. Clinical judgment is
needed to determine the urgency of completing the evaluation.
History [R]
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Symptoms
Eatinghabits,weighthistory
Physicalactivity
Priororcurrentinfections,particularlyskin,foot,dental,andgenitourinary
Symptomsandtreatmentofchroniccomplicationsassociatedwithdiabetes:eye,heart,kidney,nerve,
genitourinary (including sexual function), peripheral vascular, and cerebrovascular (these may be present at
diagnosis)
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Currentmedicationsincludingover-the-counter medications, dietary supplements and alternative therapies

with a focus on medications known to induce diabetes-type states (e.g., steroids, atypical antipsychotics)
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Psychosocial,cultural,andeconomicfactorsthatmightinfluencethemanagementofdiabetes
Alcohol/druguse
Physical Examination [R]

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Weight,height,bodymassindex(BMI),bloodpressure
Cardiovascularsystem:heart,bloodpressure,peripheralvascularincludingpulsesandbruits(abdominal,
carotid, femoral)
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Feet:nails,webspaces,ulcers,pulses,calluses,structuraldeformities,protectivesensationandshoes
Otherexaminationsasguidedbythepatient'ssymptomsand/orconcerns:
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Skin:infectionsordiseasessuchasacanthosisnigricans,xanthoma
Neurologicalsystem:sensorystateofhandsandfeet,musclewasting,deeptendonreflexes
Mentalhealth:screenfordepressionand/oranxiety
Referraltoaneyespecialisttoassessoptichealth
Referraltoadentisttoassessoralhealth
Laboratory Evaluation
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Fastingplasmaglucoseorrandomplasmaglucose
Glycosylatedhemoglobin(A 1c ) (not required for prediabetes)
Fastinglipidprofile:totalcholesterol,high-density lipoprotein (HDL cholesterol) low-density lipoprotein (LDL)

cholesterol, and triglycerides
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Serumcreatinineandliverfunctiontest(alanineaminotransferase[ALT]andaspartateaminotransferase
[AST])
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Urine:ketones,glucose,protein,microalbuminuria,cultureifmicroscopicisabnormalorsymptomsofinfection
present
Urine microalbumin tests can identify patients with early diabetic nephropathy when intervention may be most
effective in delaying or preventing end stage renal disease. Single tests for urinary microalbumin and urinary
creatinine can accurately detect urinary microalbumin excretion.
For more information see Annotation #35, "Annual Assessment of Complications." [B], [R]
Increased urinary microalbumin is a predictor of increased cardiovascular mortality [R].
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3.Diagnosis of Prediabetes
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Fastingplasmaglucoseof100mg/dLto125mg/dL
Oralglucosetolerancetest2-hour plasma glucose: 140 mg/dL to 199 mg/dL
[R]
Urine microalbumin tests can identify patients with early diabetic nephropathy when intervention may be most
effective in delaying or preventing end stage renal disease. Single tests for urinary microalbumin and urinary
creatinine can accurately detect urinary microalbumin excretion.
For more information see Annotation #35, "Annual Assessment of Complications." [B], [R]
Increased urinary microalbumin is a predictor of increased cardiovascular mortality [R].
3.Diagnosis of Prediabetes
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Fastingplasmaglucoseof100mg/dLto125mg/dL
Oralglucosetolerancetest2-hour plasma glucose: 140 mg/dL to 199 mg/dL
[R]
4.Treatment to Prevent or Delay Progression to Diabetes
Patients who are identified with prediabetes should be referred for education and lifestyle interventions. Health
care providers should follow up with patients diagnosed with prediabetes on an annual basis to monitor their
progress and review treatment goals [R].
Intensive lifestyle change programs have been proven effective in delaying or preventing the onset of diabetes by
about 50%. Effective lifestyle changes include setting achievable goals, obtaining weight loss when needed (ideally
at least 5% total body weight), and increasing physical activity [A].
Lifestylemodifications,suchasnutrition,exerciseandevenmodestweightloss,arerecommendedfor
prevention or delayed progression of patients with prediabetes.
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Pharmacotherapy,suchasmetformin,iseffectiveinsomepatientswithprediabetes.
ThereareconcernsthattherecentmodificationofthedefinitionofimpairedfastingglucosebytheAmerican
Diabetes Association has low specificity and low positive predictive value compared to the World Health
Organization (WHO) definition.
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[Conclusion Grade II: See Conclusion Grading Worksheet A Annotation #4 (Prediabetes) in the original guideline
document]
The following initial approaches are recommended for people with prediabetes:
Intensivelifestylebehavioralchangeincludinganutritionandactivityplanbyaregistereddietitian,health
educator or other qualified health professional. Ongoing support of behavioral change is necessary.
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Cardiovascularriskreductionappropriatetotheneedsoftheindividual
Patients who respond to lifestyle interventions:

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Annualfollow-up and reassessment of risks for developing diabetes [A], [R]
Patients who are high risk and not responding to lifestyle interventions:
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Intensifyeducationandcounselingonlifestyleinterventions.
Thereissomeevidenceofpreventionofdiabetesthroughpharmacotherapywithbiguanidesandalpha
glycosidase inhibitors [A], [M]. Rosiglitazone has been shown to prevent diabetes, but the risk of congestive
heart failure was increased [A]. Lifestyle change remains the preferred method to prevent diabetes [A], [M].
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5.Diagnosis of Type 2 Diabetes

Diagnosis of type 2 diabetes [R]:
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Fastingplasmaglucosegreaterthanorequalto126mg/dLontwoseparateoccasions.
Casualplasmaglucosegreaterthanorequalto200mg/dLplustypicalsymptomsofdiabetes
Intheabsenceofunequivocalhyperglycemiaassociatedwithacutemetabolicdecompensation,theresults
should be confirmed by repeat testing on a different day.
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AtthepresenttimeA1cshouldnotbeusedtodiagnosediabetes.
History
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Detailsofprevioustreatmentprograms,includingdiabeteseducation
Currenttreatmentofdiabetes,includingmedications,nutrition,physicalactivitypatternsandresultsof
glucose monitoring
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Frequency,severityandcauseofacutecomplicationssuchashypoglycemia,hyperglycemiaandnon-ketotic
hyperosmolar coma
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6.Should Patient Be Hospitalized?

Inpatient care may be appropriate in the following situations [R]:
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Elderlypatientswithinfectionorillness,weightloss,dehydration,polyuriaorpolydipsia
Life-threatening acute metabolic complications of diabetes:
Hyperglycemichyperosmolarstatewithimpairedmentalstatus,elevatedplasmaosmolalitythatincludes
plasma glucose greater than 600 mg/dL
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Diabeticketoacidosiswithaplasmaglucosegreaterthan250mg/dL,arterialpHlessthan7.30andserum
bicarbonate level less than 15 mEq/L and the presence of moderate ketonuria and/or ketonemia
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Hypoglycemiawithneuroglycopeniathatincludesbloodglucoselessthan50mg/dLandtreatmenthasnot
resulted in prompt recovery, coma, seizures or altered behavior
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Uncontrolledinsulin-requiring diabetes during pregnancy
Surgery,infection,steroids if these conditions cause significant hyperglycemia and rapid initiation of

rigorous insulin is needed
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7.Inpatient Diabetes Management

The following are recommended in the inpatient setting [R]:
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Intensiveinsulintherapywithintravenousinsulinincriticallyillpatients[R]
Useofscheduledinsulin,withbasalcoverage(improvesglucosecontrolcomparedtoslidingscalecoverage
alone)
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Forinsulin-deficient patients, despite reductions or the absence of caloric intake, basal insulin must be
Surgery,infection,steroids if these conditions cause significant hyperglycemia and rapid initiation of

rigorous insulin is needed
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7.Inpatient Diabetes Management

The following are recommended in the inpatient setting [R]:
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Intensiveinsulintherapywithintravenousinsulinincriticallyillpatients[R]
Useofscheduledinsulin,withbasalcoverage(improvesglucosecontrolcomparedtoslidingscalecoverage
alone)
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Forinsulin-deficient patients, despite reductions or the absence of caloric intake, basal insulin must be
provided to prevent diabetic ketoacidosis.
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Targetpreprandialplasmaglucoselevelsare90to130mg/dL[R]
Ifmeasured,thetargetpostprandialplasmaglucoseislessthan180mg/dL[R]
Establishingamultidisciplinaryteamthatsetsandimplementsinstitutionalguidelines,protocols,and
standardized order sets for the hospital results in reduced hypoglycemic and hyperglycemic events.
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Other considerations include [R]:

Forpatientswhoarealertanddemonstrateaccurateinsulinself-administration and glucose monitoring,
insulin self-management should be allowed as an adjunct to standard nurse-delivered diabetes management.
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Patientswithnopriorhistoryofdiabeteswhoarefoundtohavehyperglycemia(randomfastingbloodglucose
greater than 125 mg/dL or random glucose of 200 mg/dL or more) during hospitalization should have follow-up
testing for diabetes within 1 month of hospital discharge [B].
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Please see ICSI's Subcutaneous Insulin Management order set for additional information regarding inpatient glucose
management.
8.Does Patient Need Outpatient Stabilization?
Indications for immediate insulin treatment in type 2 diabetes mellitus [A], [R]:
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Severesymptoms,markedweightloss,polyuria,polydipsia
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Fastingplasmaglucosegreaterthan300mg/dLfasting,or
Randomglucoseover350mg/dL,or
A1cover10%,or
Presenceofketonuria
Insulin therapy may not be permanent once patient is stabilized.

9.Initial Stabilization for Outpatients Requiring Immediate Insulin Treatment
If the patient presents and is considered stable enough for outpatient care but meets indications noted above for
starting insulin, there are several acceptable ways of initiating insulin.
Oneexampleistocalculatethetotaldailydoseofinsulinat0.3units/kgandstartbedtimeglargineat50%
of the total dose, splitting the remaining 50% with short acting insulin before meals.
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Anotherexampleistostartanoralagentwhilesimultaneouslyinitiatingglargineatadoseofapproximately
0.1 units/kg.
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Athirdexampleistocalculatethetotaldailydoseofinsulinat0.3units/kgandusepre-mixed insulin with

2/3 the dose in the a.m. and 1/3 in the p.m.
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At presentation, all patients should be instructed on blood glucose monitoring, hypoglycemia recognition and
treatment, and how/when to contact health care support. Patients should check glucose frequently when insulin is
initiated. Patients should receive daily phone or visit contact for at least 3 days and have 24-hour emergency phone
support if needed.
Patients should be referred for nutrition and diabetes education and be seen in a timely way after diagnosis, (e.g.,
within 1 to 7 days).
Insulin therapy may not be permanent, particularly if oral agents are added or if, at presentation, the patient is in
metabolic stress such as infections, acute metabolic complications, recent surgery [D]. As the metabolic stress
resolves, the insulin dose requirements may rapidly fall.
For the occasional unstable patient with type 2 diabetes, maximal doses of oral hypoglycemic agents may afford an
approach to the patient who is psychologically resistant to or refuses insulin initiation.
10.
Recommend Education and Self-Management
Nutrition Therapy
Medical nutrition therapy for diabetes emphasizes improving metabolic outcomes by modifying nutrient intake and
lifestyle. Major goals are to attain and maintain in the normal or as close to normal range as is safely possible
blood glucose, blood pressure, and lipid/lipoprotein levels. These prevent or slow the development of chronic
complications of diabetes [R].
The priority for nutrition therapy for type 2 diabetes is to implement lifestyle strategies that will reduce
hyperglycemia and hypertension and improve dyslipidemias [R]. Because many individuals are insulin resistant and
overweight or obese, nutrition therapy often begins with strategies that reduce energy intake and increase energy
expenditure through physical activity. Many individuals may have already tried unsuccessfully to lose weight and it
is important to note that lifestyle strategies, independent of weight loss, can improve glucose control and risk
factors for cardiovascular disease.
Moderate weight loss (5% of body weight) is associated with decreased insulin resistance, improved measures of
glycemic and lipidemia, and reduced blood pressure. The optimal macronutrient distribution of weight loss diets has
not been established [R].
Low carbohydrate diets, restricting total carbohydrate to less than 130 g/day, are not recommended in the
management of diabetes.
Appropriate nutrition therapy will be developed collaboratively with the person who has diabetes. Instruction may
require a provider with expertise in medical nutrition therapy, and instruction may be obtained through individual or
group consultation [A]. It is important that physicians understand the general principles of medical nutrition
therapy and support them for patients with diabetes. In most people, nutrition recommendations are similar to
those of the general population. Medical nutrition therapy is a Medicare Part B covered benefit.
Moderate weight loss (5% of body weight) is associated with decreased insulin resistance, improved measures of
glycemic and lipidemia, and reduced blood pressure. The optimal macronutrient distribution of weight loss diets has
not been established [R].
Low carbohydrate diets, restricting total carbohydrate to less than 130 g/day, are not recommended in the
management of diabetes.
group consultation [A]. It is important that physicians understand the general principles of medical nutrition
therapy and support them for patients with diabetes. In most people, nutrition recommendations are similar to
those of the general population. Medical nutrition therapy is a Medicare Part B covered benefit.
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Evaluatethepatient'scurrenteatinghabitsandmodifyasneeded.Recommend:
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Workingtogethertowardgradual,realisticandculturallyappropriatelifestylechangegoals.
Maintainingthepleasureofeatingbylimitingonlyfoodchoicesindicatedbyscientificevidence.
Healthfulfoodchoices:foodscontainingcarbohydratesfromwholegrains,fruits,vegetablesandlowfatmilk
should be included in a healthy eating plan.
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Reducingtotalcaloricintakebymoderatingfood/beverageandlimitingtotalfatintake.
Distributingcarbohydratesevenlythroughoutthedaytosmallermealsandsnacks.
Monitoringcarbohydratesremainsakeystrategyinachievingglycemiccontrol,whetherbycarbohydrate
counting, exchanges, or experience-based estimation [R].
l
Ifonechoosestodrinkalcohol,andhasnotbeencautionedagainstit,limitintaketoonedrinkperdayfor
women and two drinks per day for men, according to U.S. Department of Agriculture (USDA) guidelines. A drink
is defined as 12 oz. of regular beer, 5 oz. of wine, or 1.5 oz. of 80-proof distilled spirits. To reduce the risk of
hypoglycemia, alcohol should be consumed with food.
l
Individualizethenutritionprescriptionbasedonthenutritionassessmentandtreatmentgoalsofeach
patient. For example, if the patient has been eating 45% of calories from fat, lowering fat to even 40% can be
helpful.
l
Carbohydrate [R]
l
Boththequantityandthetypeorsourceofcarbohydrateinfoodinfluencespost-prandial glucose levels.
Forindividualswithdiabetes,theuseofglycemicindexandglycemicloadmayprovideamodestadditional
benefit for glycemic control over that observed when total carbohydrate is considered alone.
l
Sucrose(e.g.,tablesugar)andsucrose-containing foods do not need to be restricted. However, they should

be substituted for other carbohydrate sources, or if added, covered with insulin or other glucose-lowering
medication. They should be eaten within the context of a healthy diet and avoid excess energy intake.
l
Addedfructoseasasweeteningagentisnotrecommendedasitmayadverselyaffectplasmalipids.Naturally
occurring fructose in fruits, vegetables and other foods does not need to be avoided.
l
Theuseofsugaralcohols,suchassorbitolormannitolinsmallamounts,appearstobesafehowever,they
may cause gastrointestinal side effects. When calculating carbohydrate content of foods containing sugar
alcohols, subtract half of sugar alcohol grams from total carbohydrate grams [R].
l
Sugaralcoholsandnon-nutritive sweeteners are safe when consumed within the acceptable daily intake levels
established by the Food and Drug Administration.
l
Encourageconsumingawidevarietyoffiber-containing foods such as legumes, fiber-rich cereals, fruits,

vegetables and whole grain products to achieve fiber intake goals of 14 g/1,000 calories.
l
Protein [R]
15%-20% of the total calories. Avoid protein intakes of greater than 20% of total daily energy. The long-term
effects of consuming more than 20% of energy as protein on the development of nephropathy have not been
determined. High-protein diets are not recommended as a method of weight loss at this time.
l
Reductionofproteinintaketo0.8-1 gm/kg in individuals with diabetes in the earlier stages of chronic kidney
disease and to 0.8 gm/kg in the later stages of chronic kidney disease is recommended and may improve
measures of renal function (urine albumin excretion rate, glomerular filtration rate).
l
Proteindoesnotincreaseplasmaglucoseconcentrationsbutdoesincreaseseruminsulinresponses,andthus
protein should not be used to treat acute or prevent nighttime hypoglycemia.
l
Fat [R]
Patientswithnormalweightandlipids:continuemaintaininghealthyweightandlipidsthatincludelessthan
or equal to 30% calories from fat, less than 7% saturated fats, limit of trans fats, and less than 200 mg
cholesterol [R]
l
Weightcontrol:balancelowerfatandcaloricconsumptionwithregularphysicalactivityof30minutesmost
days.
l
PatientswithelevatedcholesterolandLDL-cholesterol: implement National Cholesterol Education Program

(NCEP)-Therapeutic Lifestyle recommendations. Program-Therapeutic Lifestyle Diet: reduce saturated fat to less
than 7% calories and cholesterol less than 200 mg, consider increased soluble fiber intake (10 to 25 g/day) and
plant stanols/sterols (2 g/day), and minimize trans fat intake.
l
Twoormoreservingsoffishperweek(withtheexceptionofcommerciallyfriedfishfillets)provideomega-3
fatty acids and are recommended.
l
Patientswithelevatedtriglycerides:improvebloodglucosecontrol,encourageweightloss,increasephysical
activity, moderate carbohydrate intake and limit dietary saturated fat and trans fat. Increase consumption of
omega-3 fatty acids from fish or supplements, which has been shown to reduce adverse cardiovascular outcomes
[M].
l
Sodium [R]
Medicalnutritiontherapyforhypertensioncontrolfocusesonweightreductionandrecommendedsodium
intakes of 2,300 mg/day for normotensive and hypertensive individuals and a sodium intake less than 2,000 mg
per day for patients with diabetes and symptomatic heart failure. Additional recommendations include consuming
five to nine servings of fruits and vegetables daily, and two to four daily servings of low-fat dairy products rich in
calcium, magnesium, and potassium.
l
Supplements [R]
l
omega-3 fatty acids from fish or supplements, which has been shown to reduce adverse cardiovascular outcomes
[M].
Sodium [R]
Medicalnutritiontherapyforhypertensioncontrolfocusesonweightreductionandrecommendedsodium
intakes of 2,300 mg/day for normotensive and hypertensive individuals and a sodium intake less than 2,000 mg
per day for patients with diabetes and symptomatic heart failure. Additional recommendations include consuming
five to nine servings of fruits and vegetables daily, and two to four daily servings of low-fat dairy products rich in
calcium, magnesium, and potassium.
l
Supplements [R]
Routinesupplementationwithantioxidants,suchasvitaminsEandCandcarotene,isnotadvisedbecauseof
lack of evidence of efficacy and concern related to long-term safety.
l
Benefitfromchromiumsupplementationinpeoplewithdiabetesorobesityhasnotbeenconclusively
demonstrated and, therefore, cannot be recommended.
l
Physical activity and behavior modification are important components of weight loss programs and are most helpful
in maintenance of weight loss.
Structured programs that emphasize lifestyle changes including education, reduced energy and fat intake
(approximately 30% of total energy), regular physical activity and frequent participant contact are necessary to
produce long-term weight loss of 5%-7% of starting weight. Lifestyle change should be the primary approach to
weight loss [R].
When usual measures to promote weight loss are unsuccessful in severely obese individuals with comorbidities,
there may be a role for adjunctive pharmacotherapy or surgical procedures.
There is some evidence that pharmacotherapy for weight loss may offer short-term benefit for a subset of patients
with type 2 diabetes [A].
Patients should be provided with ongoing nutrition self-management and care support [R].
Physical Activity
People with diabetes should perform at least 150 minutes a week of moderate intensity activity (50% to 70%
maximum heart rate), and strengthening exercises three times a week unless contraindicated.
The positive benefits of physical activity include improved blood pressure values, improved lipid profile, improved
cardiac status, increased insulin sensitivity, more effective weight management, and improved glycemic control, and
it helps in the management of depressive symptoms. Because the positive effects of increased physical activity
diminish within days of the cessation of exercise, regular activity is recommended [D].
Recent studies indicate that cumulative daily physical activity may be almost as beneficial as continuous physical
exertion [A], [R]. The major emphasis is to gradually increase level of physical activity either by increasing duration
or frequency.
Epidemiological studies suggest that regular aerobic physical activity is beneficial for the treatment of type 2
diabetes mellitus [C], [R].
Reinforce the ongoing need and benefits of physical activity at each visit, offering support and advice on ways to
incorporate 30 minutes of physical activity into most days of the week [R].
Results of self-monitoring glucose can be useful in preventing hypoglycemia and adjusting medications, medical
nutrition therapy and physical activity.
Hypoglycemia is a risk in individuals who participate in physical activity and are taking insulin, sulfonylureas and/or
meglitinides. Depending on the level of physical activity, the medication dosage or the amount of carbohydrate
ingested, hypoglycemia can occur. For patients on these drug classes and pre-exercise glucose monitor results less
than 100 mg/dL, additional carbohydrate should be ingested for prevention of hypoglycemia [R].
Strategies for Initiation of Increased Physical Activity
l
Startbyincorporating10minutesofincreasedactivityintoeachday.
l
Usestairsinsteadofelevator.
Parkcarawayfrombuildingentranceandwalk.
Walktodoerrands.
Overcomebarriers.
l
Selfmonitoractivityperformedusingpedometer,timerecord,and/orjournal.
Beconsistent.
Havealternativeactivitiesforinclementweather.
Findenjoyableactivities.
Beactiveatthetimeofdaythatisbestfortheindividual.
Doingaphysicalactivityand/orbeingaccountabletosomeoneregardingyourprogressgreatlyimprovesthe
ability to be successful [R].
l
Medical Evaluation to Assess Safety of Exercise Program

l
Assessphysicalconditionandlimitationsofthepatient.
Assessforcardiovasculardisease.Atypicalsymptomsandpainlessischemiaaremorecommoninpatientswith
diabetes [D].
l
Cardiacstresstesting:thereisnoevidencethatstresstestingisroutinelynecessaryinasymptomaticpeople
before beginning a moderate-intensity exercise program such as walking.
l
Cardiacstresstestingshouldbeconsideredforthepreviouslysedentaryindividualatmoderatetohigh-risk for
cardiovascular disease or other patients who are clinically indicated who want to undertake vigorous aerobic
exercise that exceeds the demands of everyday living [R].
l
Assessbloodglucosecontrol.
Assessknowledgeofphysicalactivityinrelationtobloodglucosecontrol.
Whenmakingareferral,makeotherhealthcareprovidersawareoflimitationsforexercise.
Physical activity can be intermittent or cumulative [A], [R].
Cardiacstresstesting:thereisnoevidencethatstresstestingisroutinelynecessaryinasymptomaticpeople
before beginning a moderate-intensity exercise program such as walking.
l
Cardiacstresstestingshouldbeconsideredforthepreviouslysedentaryindividualatmoderatetohigh-risk for
cardiovascular disease or other patients who are clinically indicated who want to undertake vigorous aerobic
exercise that exceeds the demands of everyday living [R].
l
Assessbloodglucosecontrol.
Assessknowledgeofphysicalactivityinrelationtobloodglucosecontrol.
Whenmakingareferral,makeotherhealthcareprovidersawareoflimitationsforexercise.
Physical activity can be intermittent or cumulative [A], [R].

Weight Management
When usual measures to promote weight loss are unsuccessful in severely obese individuals with comorbidities,
there may be a role for adjunctive pharmacotherapy or surgical procedures.
There is some evidence that pharmacotherapy for weight loss may offer short-term benefit for a subset of patients
with type 2 diabetes [A]. The studies, however, were of relatively weak design, and pharmacotherapy for weight
loss cannot be recommended for most patients with type 2 diabetes.
Bariatric surgery has recently been discussed as an option for some individuals with type 2 diabetes who have a
body mass index of 35 kg/m 2 or more. Bariatric surgery can result in marked improvements in glycemia; however,
the long-term benefits and risks need to be studied further [R].
Weight loss is also an important goal because it improves insulin resistance, glycemic control, blood pressure, and
lipid profiles. Moderate weight loss (5% of body weight) can improve fasting blood glucose in many overweight or
obese persons [R]. Low-carbohydrate diets, restricting total carbohydrate to less than 130 g/day, are not
recommended in the management of diabetes.
There is considerable interest in low-carbohydrate diets for weight loss; however, the long-term effects of these
diets are unknown and although such diets produce short-term weight loss, maintenance of weight loss is similar to
that of low-fat diets, and impact on cardiovascular disease risk profile is uncertain [R].
Low-carbohydrate diets, restricting total carbohydrate to less than 130 g/day, are not recommended in the
management of diabetes. For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be
effective in the short-term (up to one year) [R].
Please see the NGC summary of the ICSI guideline Prevention and Management of Obesity (Mature Adolescents and
Adults) for more information.
group consultation [A], [M], [R]. It is important that physicians understand the general principles of medical
nutrition therapy and support them for patients with diabetes. In most people, nutrition recommendations are
similar to those of the general population. Medical nutrition therapy is a Medicare Part B covered benefit.
Education for Self-Management
Adequate self-management support for patients requires integration of available self-management education and
support resources into routine care. Usually appropriate education may require the expertise of the diabetes
educator. This instruction can be obtained through individual or group consultation [A], [M], [R]. Medicare
reimbursement for diabetes self-management training requires this service be provided by an education program
that has achieved recognition by the American Diabetes Association or American Association of Diabetes Educators;
thestaffinsuchaprogramaremultidisciplinaryandincludeatleastaregistereddieticianandaregisterednurse
with experiential preparation in education and diabetes management [R]. A number of studies involving a clinical
pharmacist in program with cardiac risk factors in select patients with diabetes have proven to be effective [D].
Providers should be aware of culturally appropriate educational and community resources to support persons with
diabetes and their families.
An education plan should be identified based on the needs of the individual and referral made to either an internal
or external education resource. Periodic reassessment of educational goals is recommended [D], [R].
See the Support for Implementation Section in the original guideline document for a list of American Diabetes
Association-recognized education programs available.
Components of self-management include:
l
Descriptionofthediabetesdiseaseprocessandtreatmentoptions
Goalsettingtopromotehealth,andproblemsolvingfordailyliving
Preventing,detecting,andtreatingacutecomplications
Preventing(throughriskreductionbehavior),detecting,andadheringtotreatmentsforchroniccomplications
Selfmonitoringbloodglucose,ketones(whenappropriate),andusingresultstoimprovecontrol
Incorporationofappropriatenutritionmanagement[C]
Incorporationofphysicalactivityintolifestyle[C]
Utilizingmedications(ifapplicable)fortherapeuticeffectiveness
Awarenessofculturallyappropriatecommunityresources/supportforpersonswithdiabetesmellitusandtheir
families, and ability to access community resources
l
Psychosocialadjustmenttodailylife
Promotionofpreconceptioncare,counseling,andmanagementduringpregnancy,ifapplicable
Foot Care
Education should be tailored to patient's current knowledge, individual needs, and risk factors. Patients should be
aware of their risk factors and appropriate measures to avoid complications [R]. (See Annotation # 35, "Annual
Assessment of Complications, Comprehensive Foot Exam with Risk Assessment" below.)
Education should cover:
l
Inspectfeetdailyforcuts,bruises,bleeding,redness,andnailproblems.
Washfeetdailyanddrythoroughlyincludingbetweenthetoes.
Donotsoakfeetunlessspecifiedbyahealthcareprovider.
Foot Care
Education should be tailored to patient's current knowledge, individual needs, and risk factors. Patients should be
aware of their risk factors and appropriate measures to avoid complications [R]. (See Annotation # 35, "Annual
Assessment of Complications, Comprehensive Foot Exam with Risk Assessment" below.)
Education should cover:
l
Inspectfeetdailyforcuts,bruises,bleeding,redness,andnailproblems.
Washfeetdailyanddrythoroughlyincludingbetweenthetoes.
Donotsoakfeetunlessspecifiedbyahealthcareprovider.
Becarefulofhotwater.
Useoflotions,creamsormoisturizerisacceptable,butdonotusebetweenthetoes.
Donotwalkbarefoot.
Checkshoeseachdayforobjectsthatmayhavefalleninside,excessivewear,orareasthatmaycause
irritation.
l
Avoidinjuriesfromcuttingtoenailsavoidself-cutting calluses or corns.
Whentoseekcare
Community Resources
There is some evidence for the effectiveness of community-based diabetes self-management education and
support. These programs may complement the care and education that are routinely part of standard medical
practice, and may enhance a patient's ability to self-manage diabetes. The Task Force on Community Preventive
Services, supported by the Centers for Disease Control and Prevention, recommends diabetes self-management
education in community gathering places.
11.
Set Personalized A1c Goal = A1c Less Than 7% or Individualized to a Goal Less Than 8% Based on Factors
in 11a (see the algorithm box 11a in the original guideline document)
Key Points:
IndividualA1candothertreatmentgoalsshouldbebasedontherisksandbenefitsforeachpatient.Set
personalized A1c goal less than 7% or individualize to goal less than 8% based on complex patient factors.
l
A1c target in type 2 diabetes is aimed at reducing microvascular complications while not increasing risk of morbidity
or mortality.
Allpatientswithtype2diabetesshouldaimtoachieveanA1clessthan8%.Thiswillreducemicrovascular
disease and not increase risk substantially.
l
Most(many)patientswithtype2diabetesmayderiveadditionalbenefitinreductionofmicrovasculardisease
by reaching a target A1c less than 7% (and not increase risks as long as the target is not A1c less than 6%).
l
[Conclusion Grade II: See Conclusion Grading Worksheet B Annotation #11 (A1c) in the original guideline
document].
The work group defines high cardiovascular risk as the patient having two other cardiovascular risks (obesity,
hypertension, dyslipidemia, smoking, and proteinuria). Alternative approaches to calculate cardiovascular risk
include the Framingham equation, Archimedes, and United Kingdom Prospective Diabetes Study Group (UKPDS).
The physician and patient must discuss and document specific treatment goals and develop a plan to achieve all
desired goals. A multifactorial approach to diabetes care that includes emphasis on blood pressure, lipids, glucose,
aspirin use, and non-use of tobacco will maximize health outcomes far more than a strategy that is limited to just
one or two of these clinical domains [A], [R].
For patients with type 2 diabetes and the following factors, an A1c goal of less than 8% may be more appropriate
than an A1C goal of less than 7% [A].
l
Knowncardiovasculardiseaseorhighriskcardiovascularrisk
Inabilitytorecognizeandtreathypoglycemia,historyofseverehypoglycemiarequiringassistance
Inabilitytocomplywithstandardgoals,suchapolypharmacyissues
Limitedlifeexpectancyorestimatedsurvivaloflessthan10years
Cognitiveimpairment
Extensivecomorbidconditionssuchasrenalfailure,liverfailureandend-stage disease complications
Glycosylated hemoglobin assays provide an accurate indication of long-term glycemic control. A1 is formed by the
continuous non-enzymatic glycosylation of hemoglobin throughout the lifespan of an erythrocyte. This assay yields
an accurate measure of time-averaged blood glucose during the previous six to eight weeks.
There are various methodologies (e.g., HbA, A1c, glycated hemoglobin) for this assay. At present, there are no
established criteria for use as a diagnostic test. Clinically it can assist in determining duration and severity of
hyperglycemia and can help guide treatment.
Eating, physical activity or acute metabolic stress do not influence the A1c test. The test can be done at any time
of day and does not require fasting.
Glucose should also be used to assess level of glycemic control, in addition to A1c. It is appropriate to determine
need for medication changes based on blood glucose whenever this information is available.
Self-Monitoring Blood Glucose (SMBG)
Major clinical trials assessing the impact of glycemic control on diabetes complications have included SMBG as
part of multifactorial interventions, suggesting that self-monitoring blood glucose is a component of effective
therapy [R]. However, there have been few large published studies done specifically to assess the link between
self-monitoring blood glucose and A1c levels. Refer to Table 1 in the original guideline document for information
on ranges of self-monitored glucose readings that would be expected for patients with the corresponding A1c
levels.
Self-monitoring blood glucose allows patients to evaluate their individual response to therapy and assess whether
glucose targets are being achieved. Results of self-monitoring blood glucose can be useful in preventing
hypoglycemia and adjusting medications, medical nutrition therapy and physical activity [R].
The frequency and timing of self-monitoring blood glucose should be dictated by the particular needs and goals of
the individual patient. Patients with type 2 diabetes on insulin typically need to perform self-monitoring blood
l
Major clinical trials assessing the impact of glycemic control on diabetes complications have included SMBG as
part of multifactorial interventions, suggesting that self-monitoring blood glucose is a component of effective
therapy [R]. However, there have been few large published studies done specifically to assess the link between
self-monitoring blood glucose and A1c levels. Refer to Table 1 in the original guideline document for information
on ranges of self-monitored glucose readings that would be expected for patients with the corresponding A1c
levels.
Self-monitoring blood glucose allows patients to evaluate their individual response to therapy and assess whether
glucose targets are being achieved. Results of self-monitoring blood glucose can be useful in preventing
hypoglycemia and adjusting medications, medical nutrition therapy and physical activity [R].
The frequency and timing of self-monitoring blood glucose should be dictated by the particular needs and goals of
the individual patient. Patients with type 2 diabetes on insulin typically need to perform self-monitoring blood
glucose more frequently than those not using insulin, particularly if using glucose readings to guide mealtime
insulin dosing. It is recommended that patients using multiple insulin injections perform self-monitoring blood
glucose three or more times daily [R]. The optimal frequency and timing of self-monitoring blood glucose for
patients with type 2 diabetes on oral agent therapy are not known but should be sufficient to facilitate reaching
glucose goals. Self-monitoring blood glucose should be performed more frequently when adding or modifying
therapy; two-hour postprandial glucose testing is useful in some patients. The role of self-monitoring blood
glucose in stable diet-treated patients with type 2 diabetes is not known.
Because the accuracy of self-monitoring blood glucose is instrumental and user dependent, it is important for
health care providers to evaluate each patient's monitoring technique. In addition, optimal use of self-monitoring
blood glucose requires proper interpretation of the data. Patients should be taught how to use the data to adjust
food intake, exercise or pharmacological therapy to achieve specific glycemic goals.
See the original guideline document for examples of self-monitoring glucose goals, frequency, and timing.
13.
Treatment Goals for Patients without Cardiovascular Disease
Key Points:
Amajorfocusofdiabetescareistoachievethefollowingtreatmentgoals:useofstatinsinalladulttype2
diabetes patients if tolerated; statins should be titrated to achieve low-density lipoprotein cholesterol of less
than 100 mg/dL without coronary artery disease, blood pressure less than 130/80 mmHg. Set personalized A1c
goal = A1c less than 7% or individualized to goal of less than 8% based on risk factors. Daily aspirin use is
optional for primary prevention of cardiovascular events.
l
Consider Statin, unless Contraindicated

For patients with type 2 diabetes mellitus, consider the use of a statin. Randomized controlled trials, including a
number of large trials, and observational data consistently show a benefit of statin therapy for patients with type
2 diabetes. Some studies also report that statin therapy was well tolerated in these patients. However, none of
these studies was able to assess long-term effects of statin treatment/use. [Conclusion Grade I: See Conclusion
Grading Worksheet C Annotations #13, 14 (Statin Use) in the original guideline document]. Evidence and Adult
Treatment Panel III consensus guidelines suggest that statins are beneficial for high-risk patients ages 40 to 80
years with a 10-year risk of cardiovascular event of more than 20%, even with baseline untreated low-density
lipoprotein of less than 100 mg/dL [A], [R]. There is an online and a Palm format-downloadable cardiovascular risk
calculator that is used in assessing 10-year risk of cardiovascular disease used in the Adult Treatment Panel III
guideline report and this guideline on lipid management [R]. The links are:
l
Online calculator: http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof

Palm format (downloadable): http://hin.nhlbi.nih.gov/atpiii/riskcalc.htm
[Conclusion Grade I: See Conclusion Grading Worksheet C Annotations #13, 14 (Statin Use) in the original
guideline document] [A].
LDL Less than 100 mg/dL
The low-density lipoprotein cholesterol goal for people with diabetes mellitus without coronary artery disease is
less than 100 mg/dL.
Intensify statin or lipid-lowering medications to meet low-density lipoprotein cholesterol goals [A].
Three pathways to improve lipids are:
l
Medicalnutritiontherapy
Increasedphysicalexercise
Pharmacotherapy
Beneficial effects of statins on cardiovascular risk reduction may go beyond their effects on lipid levels. Diabetes
is considered a coronary artery disease equivalent.
There currently is little evidence for safety and efficacy of combination therapy with statins and other lipid drugs.
National Institutes of Health-sponsored randomized controlled studies are currently underway to determine
whether adding fibrates or niacin to statin therapy will lower the risk of cardiovascular events for patients with
diabetes. ACCORD (fibrate plus statins in diabetes patients) results will be reported in early 2010, and AIM-HIGH
(niacin plus statin) will be reported circa 2012.
High triglycerides and low high-density lipoprotein cholesterol levels are independent risk factors for
cardiovascular disease in the patient with diabetes [R]. Individuals with elevated triglycerides have significant
cardiovascular risk reduction with the use of fibrates [A] or statins [A]. While a number of studies support
favorable changes in lipid profiles with niacin alone, randomized controlled trials considering hard cardiovascular
outcomes are still underway (AIM-HIGH).
GoalsforBloodPressureControlBloodPressureLessThan130/80mm/Hg,EmphasisonSystolicBlood
Pressure Control [R]
Uncontrolled hypertension is a major cardiovascular risk factor that also accelerates the progression of diabetic
nephropathy [B]. When hypertension is identified, it should be aggressively treated to achieve a target blood
pressure of less than 130/80 mm Hg. In many patients with diabetes, two or three or more antihypertensive
agents may be needed to achieve this goal. The use of generic combination tablets (such as angiotensinconverting enzyme [ACE] inhibitor plus calcium-channel blocker, or else beta-blocker plus diuretic) can reduce the
complexity of the regimen and out-of-pocket costs. See the Blood Pressure Control algorithm annotations below.
For patients with type 2 diabetes mellitus, the systolic blood pressure goal is less than 130 mm Hg and the
diastolic blood pressure goal is less than 80 mm Hg. [Conclusion Grade II: See Conclusion Grading Worksheet D - Annotations #13, 14, 27, 29 (Goals for Blood Pressure) in the original guideline document] [A].
l
Aspirin/Antiplatelet Medication Optional [A]

Patients with type 2 diabetes are at a significantly high risk for development of heart disease [R]. There is
insufficient evidence to support aspirin use in the primary prevention of cardiovascular events in patients with
type 2 diabetes, although there is no evidence of significant harm. However, there is sufficient evidence to
l
pressure of less than 130/80 mm Hg. In many patients with diabetes, two or three or more antihypertensive
agents may be needed to achieve this goal. The use of generic combination tablets (such as angiotensinconverting enzyme [ACE] inhibitor plus calcium-channel blocker, or else beta-blocker plus diuretic) can reduce the
complexity of the regimen and out-of-pocket costs. See the Blood Pressure Control algorithm annotations below.
diastolic blood pressure goal is less than 80 mm Hg. [Conclusion Grade II: See Conclusion Grading Worksheet D - Annotations #13, 14, 27, 29 (Goals for Blood Pressure) in the original guideline document] [A].
Aspirin/Antiplatelet Medication Optional [A]
Patients with type 2 diabetes are at a significantly high risk for development of heart disease [R]. There is
insufficient evidence to support aspirin use in the primary prevention of cardiovascular events in patients with
type 2 diabetes, although there is no evidence of significant harm. However, there is sufficient evidence to
support the use of aspirin for secondary prevention of cardiovascular events in patients with type 2 diabetes.
[Conclusion Grade I: See Conclusion Grading Worksheet E Annotations #13, 14 (Aspirin Use) in the original
guideline document]. Some recent trials of aspirin use in diabetes have shown less benefit than older trials
(perhaps due to better background A1c, blood pressure, and low-density lipoprotein control and lower smoking
rates in recent trials) [A]. There are significant limitations identified in these studies, and more definitive studies
would be helpful. [Conclusion Grade I: See Conclusion Grading Worksheet E Annotations #13, 14 (Aspirin Use)
in the original guideline)]. Therefore, based on current evidence, low-dose aspirin is considered optional for
primary prevention.
On September 8, 2006, the Food and Drug Administration issued a Safety Information and Adverse Event Report
regarding the concomitant use of aspirin and ibuprofen. With occasional use of ibuprofen, there is likely to be
minimal risk from any attenuation of the antiplatelet effect of low-dose aspirin, because of the long-lasting effect
of aspirin on platelets. Recommendations include taking immediate-release aspirin (not enteric-coated) 30
minutes or longer prior to taking ibuprofen (400 mg). If ibuprofen is taken first, aspirin should not be taken for at
least eight hours after ingestion of ibuprofen.
l
Goals for Tobacco Use - Smoking Cessation, if Indicated

Tobacco smoking increases risk of macrovascular complications about 4% to 400% in adult with type 2 diabetes
and also increases risk of macrovascular complications. Although only about 14% of adult with diabetes in
Minnesota are current smokers, in these patients, smoking cessation is very likely to be the single most beneficial
intervention that is available, and should be emphasized by providers as described below.
l
Identifyanddocumenttobaccousestatus.
Treateverytobaccouser.Ifthepatientisunwilling,theclinicianshouldimplementmotivationaltreatments.
Individual,groupandtelephonecounselingareeffective,andtheireffectivenessincreaseswithtreatment
intensity.
l
Practicalcounseling(problem-solving/skills training and social support delivered as part of the treatment)

are especially effective counseling strategies and should be implemented by clinicians.
l
Numerouseffectivemedicationsareavailable.
Thecombinationofcounselingandmedicationismoreeffectivethaneitheralone.Therefore,clinicians
should encourage all individuals making a quit attempt to use both.
l
Telephonequitlinecounselingiseffective.Therefore,cliniciansandhealthcaredeliverysystemsshould
ensure patient access to quit lines and promote their use.
l
Tobaccodependencetreatmentsarebothclinicallyeffectiveandcosteffective.Effectiveinterventions
require coordinated interventions. Just as the clinician must intervene with the patient, so must the health care
administrator, insurer and purchaser foster and support tobacco intervention as an integral element of health
care delivery.
l
Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of
contraindications, these may be used with all patients attempting to quit smoking. Please see the NGC summary of
the ICSI guideline Preventive Services in Adults for additional information.
Tobacco telephone quit lines: HHS National Quit line (1-800-QUITNOW) or 1-800-784-8669; other local quit lines
may be available.
14.
Treatment Goals for Patients with Cardiovascular Disease
Key Points:
Amajorgoalofdiabetescareistoachievethefollowingtreatmentgoals:useofstatinsinalladulttype2
diabetes patients if tolerated; statins should be titrated to achieve low-density lipoprotein cholesterol of less
than 70 mg/dL with coronary artery disease, blood pressure less than 130/80 mm Hg. Set personalized A1c goal
= A1c less than 7% or individualized to goal of less than 8% based on risk factors. Daily aspirin use is
recommended in patients with cardiovascular disease.
l
Consider Statin, unless Contraindicated

For patients with type 2 diabetes mellitus, consider the use of a statin. Randomized controlled trials, including a
number of large trials, and observational data consistently show a benefit of statin therapy for patients with type
2 diabetes. Some studies also reported that statin therapy was well tolerated in these patients. However, none of
these studies was able to assess long-term effects of statin treatment/use. [Conclusion Grade I: See Conclusion
Grading Worksheet C Annotations #13, 14 (Statin Use) in the original guideline document] [A].
l
LDL Less Than 70 mg/dL

The low-density lipoprotein cholesterol goal for people with diabetes mellitus with coronary artery disease is less
than 70 mg/dL.
Intensify statin or lipid-lowering medications to meet low-density lipoprotein cholesterol goals [A].
Use of moderate- to high-dose statins or other low-density lipoprotein cholesterol-lowering medications as
needed to achieve a low-density lipoprotein cholesterol value less than 70 mg/dL is recommended for patients
with coronary heart disease [A].
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Pharmacotherapy
There currently is no evidence for safety and efficacy of combination therapy with statins and other lipid drugs.
diabetes.

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Pharmacotherapy
There currently is no evidence for safety and efficacy of combination therapy with statins and other lipid drugs.
diabetes.
cardiovascular disease in the patient with diabetes [R]. Individuals with elevated triglycerides have significant
cardiovascular risk reduction with the use of fibrates [A] or statins [A]. While a number of studies support
favorable changes in lipid profiles with niacin alone, randomized controlled trials considering hard cardiovascular
outcomes are still underway (AIM-HIGH).
Goals for Blood Pressure Control: Blood Pressure Less Than 130/80 mm Hg, Emphasis on Systolic Blood
Pressure Control [R]
Uncontrolled hypertension is a major cardiovascular risk factor that also accelerates the progression of diabetic
nephropathy [B]. When hypertension is identified, it should be aggressively treated to achieve a target blood
pressure of less than 130/80 mm Hg. In many diabetes patients, two or three or more antihypertensive agents
may be needed to achieve this goal. The use of generic combination tablets (such as angiotensin-converting
enzyme [ACE] inhibitor plus calcium-channel blocker, or else beta-blocker plus diuretic) can reduce the complexity
of the regimen and out-of-pocket costs. See the Blood Pressure Control algorithm annotations below.
diastolic blood pressure goal is less than 80 mm Hg. [Conclusion Grade II: See Conclusion Grading Worksheet D
Annotations #13, 14, 27, 29 (Goals for Blood Pressure in the original guideline document)] [A].
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Aspirin/Antiplatelet Medication Use unless Contraindicated [A]

There is insufficient evidence to support aspirin use in the primary prevention of cardiovascular events in patients
with type 2 diabetes, although there is no evidence of significant harm. However, there is sufficient evidence to
support the use of aspirin for secondary prevention of cardiovascular events in patients with type 2 diabetes.
[Conclusion Grade I: See Conclusion Grading Worksheet E Annotations #13, 14 (Aspirin Use) in the original
guideline document].
If aspirin is contraindicated, consider use of clopidogrel or ticlopidine. For more information, please refer to the
NGC summaries of the ICSI guidelines Stable Coronary Artery Disease and the Antithrombotic Therapy
Supplement.
On September 8, 2006, the Food and Drug Administration issued a Safety Information and Adverse Event Report
regarding the concomitant use of aspirin and ibuprofen. Health care professionals should counsel patients about
the appropriate timing of ibuprofen dosing if they are taking aspirin for cardioprotective effects. With occasional
use of ibuprofen, there is likely to be minimal risk from any attenuation of the antiplatelet effect of low-dose
aspirin, because of the long-lasting effect of aspirin on platelets. Recommendations include taking immediaterelease aspirin (not enteric-coated) 30 minutes or longer prior to taking ibuprofen (400 mg). If ibuprofen is taken
first, aspirin should not be taken for at least eight hours after ingestion of ibuprofen.
For more information, please refer to the information listed on the Food and Drug Administration's Web site for a
complete copy of the alert and cited references:
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm150611.htm
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.
Goals for Tobacco Use - Smoking Cessation, if Indicated
Refer to Annotation #13 above for information on interventions for smoking cessation.
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15.
Are Treatment Goals Met?
Major long-term goals of care in type 2 diabetes are cardiovascular disease prevention (see the related Blood
Pressure Control algorithm annotations) and achieving optimal glycemic control (see the related Glycemic Control
algorithm annotations).
Setting initial goals that are achievable, however modest they may be, may encourage patients to take further
steps along the way to the more ambitious long-term goals.
Goals and progress towards agreed-upon goals should be briefly reviewed at each office visit for diabetes.
Adjustment of goals will likely be required over time, and patient involvement in this process can increase levels of
patient involvement in care, give patients a greater sense of control of their diabetes, and allow flexibility in
management of diabetes during periods of high stress or major life transitions.
16.
Treatment Goals Not Met
Modify Treatment Based on Appropriate Related Guidelines
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Prevention and Management of Obesity (Mature Adolescents and Adults)
Hypertension Diagnosis and Treatment
Lipid Management in Adults
Major Depression In Adults in Primary Care
See the Glycemic Control and Blood Pressure Control Algorithms

Consider Referral to Diabetes Care Team or Specialists
Assess Patient Adherence
Nonadherence with medications can limit the success of therapy and help to explain why a patient is not
achieving treatment goals. To screen for nonadherence, clinicians can ask patients open-ended, nonthreatening
questions at each office visit. The assessment should include probes for factors that can contribute to non adherence (fear of adverse reactions, misunderstanding of chronic disease treatment, depression, cognitive
impairment, complex dosing regimens, or financial constraints).
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Assessthepatient'sknowledgeofhis/herconditionandhis/herexpectationsfortreatment.
Assessthepatient'smedicationadministrationprocess.
Assessthepatient'sbarrierstoadherence.
Interventions to enhance medication adherence should be directed at risk factors or causes of nonadherence.
Interventions may include simplifying the medication regimen, using reminder systems, involving family or
achieving treatment goals. To screen for nonadherence, clinicians can ask patients open-ended, nonthreatening
questions at each office visit. The assessment should include probes for factors that can contribute to non adherence (fear of adverse reactions, misunderstanding of chronic disease treatment, depression, cognitive
impairment, complex dosing regimens, or financial constraints).
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Assessthepatient'sknowledgeofhis/herconditionandhis/herexpectationsfortreatment.
Assessthepatient'smedicationadministrationprocess.
Assessthepatient'sbarrierstoadherence.
Interventions to enhance medication adherence should be directed at risk factors or causes of nonadherence.
Interventions may include simplifying the medication regimen, using reminder systems, involving family or
caregivers in care, involving multiple disciplines in team care, providing written and verbal medication
instructions, setting collaborative goals with patients, and providing education about medications (including
potential adverse effects) and about diabetes in general [R].
Evaluate for Depression
There is a substantial increase in the prevalence of depression among people with diabetes as compared to the
general adult population [M]. Self-administered or professionally administered instruments (such as the Patient
Health Questionnaire [PHQ]-9) are useful adjuncts to the clinical interview in the identification of depression.
Depression impacts the ability of a person with diabetes to achieve blood glucose control, which in turn impacts
the rate of development of diabetes complications [M], [R].
Identification and management of depression is an important aspect of diabetes care. The ICSI Major Depression
in Adults in Primary Care guideline provides more detailed suggestions for the management of depression.
Intervention studies have demonstrated that when depression is treated, both quality of life and glycemic control
improve. Counseling may be effective, especially among those who are having difficulty adjusting to the diagnosis
of diabetes or are having difficulty adjusting to the diagnosis of diabetes or are having difficulty living with
diabetes. Pharmacotherapy for depression is also effective.
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Diabetes Care Team

Assure the patient has an adequate care team.
Diabetes Educator
Consultation with a diabetes educator is suggested if the patient is having difficulty adhering to a nutrition,
exercise and medication regimen and the patient is having difficulty adhering to, or accurately completing, blood
glucose monitoring or may need answers to some questions.
Every primary care physician must develop a relationship with a diabetes education program to provide other
options for management. The American Diabetes Association publishes a list of recognized educational programs
in each state. These programs may be staffed with endocrinologists or primary care providers plus diabetes
educators including dietitians, nurses and other health care providers who are Certified Diabetes Educators or
have didactic and experiential expertise in diabetes care and education.
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Endocrinologist/Nephrologist
Most type 2 diabetes management can be managed by a primary care physician with periodic consultation as
needed by an endocrinologist.
Consultation with a specialist is suggested if persistent proteinuria, worsening microalbuminuria and elevation in
serum creatinine or blood urea nitrogen, or hypertension unresponsive to treatment is seen. For additional
discussion, see Annotation #36, "Treatment and Referral for Complications, Nephropathy".
Endocrinologist/Neurologist
Consultation with a specialist is suggested if neuropathy progresses and becomes disabling.
Endocrinologist/Cardiologist/Hypertension Specialist
Consultation with a specialist is suggested if blood pressure is refractory to treatment, the patient has marked
associated postural hypotension, or symptoms of coronary artery disease.
Foot Care Specialist
A consultation with a specialist is suggested if the patient is unable to care properly for his/her own feet, needs
prescriptive footwear and/or more serious problems such as foot deformities (e.g., Charcot deformity), infected
lesions, and ulcers, deformed nails or thick calluses are present.
Vascular Specialist/Surgeon
Consider referral if patient has symptoms of peripheral vascular disease such as loss of pulses and/or claudication.
Glycemic Control Algorithm Annotations
18.
Glycemic Control Algorithm
Medical nutrition therapy may be all that is required to treat diabetes, especially for the patient with early mild
symptomatic disease. Medical nutrition therapy should be maintained throughout the course of the disease, even as
pharmacologic agents are used. Oral agent medications are generally used if medical nutrition therapy alone does
not succeed in obtaining patients' goals within a reasonable time frame, usually no longer than 2 to 3 months.
Metformin plus lifestyle treatment is also a reasonable initial therapy at the time of diagnosis, given the low risk of
hypoglycemia and the benefits of metformin shown in both prediabetes and diabetes [R].
At the time of diagnosis, if patients have severe symptomatic disease, insulin should be initiated. With appropriate
educational support and care, the risks of insulin may not differ from many oral agents. In some circumstances
when glucose intolerance is significant and the patient is unwilling to consider insulin or it is not felt to be
appropriate, the initiation of combinations of oral agents can be appropriate. Insulin is indicated when there is a
failure to achieve treatment goals with oral agents.
It is important to remember that patients can move both ways on the Glycemic Control algorithm, (e.g., they can
move off of specific pharmacologic therapies as lifestyle changes are made that improve glycemic control). Diabetes
is a progressive disease, however, and the use of pharmacologic agents will likely become necessary in the majority
of patients, even if they are able to follow through with nutrition and physical activity recommendations [A].
19.
Pharmacologic Agent(s) - Which Is Best?
Key Points:
Ageandweightofthepatient,aswellaspresenceofrenaldysfunction,cardiopulmonarycomorbidities,and
hepatic disease must be considered when choosing pharmacologic agents.
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Only general guidelines can be given when deciding about which pharmacologic agent will be best for a specific
patient. While each patient presents with unique circumstances, the following clinical circumstances should be
It is important to remember that patients can move both ways on the Glycemic Control algorithm, (e.g., they can
move off of specific pharmacologic therapies as lifestyle changes are made that improve glycemic control). Diabetes
is a progressive disease, however, and the use of pharmacologic agents will likely become necessary in the majority
of patients, even if they are able to follow through with nutrition and physical activity recommendations [A].
19.
Pharmacologic Agent(s) - Which Is Best?
Key Points:
Ageandweightofthepatient,aswellaspresenceofrenaldysfunction,cardiopulmonarycomorbidities,and
hepatic disease must be considered when choosing pharmacologic agents.
l
Only general guidelines can be given when deciding about which pharmacologic agent will be best for a specific
patient. While each patient presents with unique circumstances, the following clinical circumstances should be
considered.
Age of Patient
It is important to recognize that risks of medications are often increased with advancing age, but this does not
justify the withholding of medications that may reduce the symptoms of polyuria, nocturia, and frequent visits to
the bathroom that may place the patient at risk of hip fracture or falls.
With age, decline in renal function is often not reflected in a measurable change in serum creatinine because of an
accompanying decline in muscle mass. Because of this, metformin should be used with caution in elderly patients
(over age 80).
Decline in ventricular function and risks for volume overload can be occult in the elderly and may become clinically
apparent with the use of thiazolidinediones.
In select circumstances, because of the risks of hypoglycemia, variable diet habits and renal clearance and function,
it may be safer to consider initial low dose short-acting sulfonylurea (e.g., glipizide or repaglinide/nateglinide when
a meal is eaten).
Weight of the Patient
Type 2 diabetes is often associated with insulin resistance and weight gain. Metformin, acarbose, exenatide,
sitagliptin, and human amylin are more often associated with weight loss or weight maintenance. Due to its weight
benefits as well as general tolerability, lower cost and proven benefits in UK Prospective Diabetes Study Group,
metformin is recommended for most diabetes patients with type 2 diabetes unless contraindicated. Insulin and
thiazolidinediones may be associated with weight gain [A].
Renal Dysfunction
Renal dysfunction increases the risk for hypoglycemia, in particular with the use of oral hypoglycemic agents.
Metformin and alpha glucosidase inhibitors should not be used.
Thiazolidinediones may be considered, but the potential risks of fluid retention need to be considered.
Short-acting oral agents glipizide, glimepiride (in which serum levels have been noted to decrease in mild renal
failure), repaglinide, or nateglinide may be preferred if an oral agent is felt to be necessary in the face of renal
dysfunction.
Insulin may be the safest when serum creatinine is greater than 1.8 mg or creatinine clearance is less than 60
mL/min.
Cardiopulmonary Comorbidities
Metformin should be used with caution in patients with conditions that predispose them to risk of hypoxia such as
congestive heart failure, chronic obstructive pulmonary disease or obstructive sleep apnea. Metformin should be
promptly discontinued in situations of cardiovascular collapse from acute congestive heart failure, acute myocardial
infarction, or any other cause.
Patients started on thiazolidinediones should be instructed to report signs of lower extremity swelling, rapid weight
gain, and shortness of breath. Risk of thiazolidinediones needs to be discussed and documented before using in
patients with cardiovascular risks. Please see the thiazolidinediones warning for more information.
Short acting sulfonylurea (e.g., glipizide), repaglinide/nateglinide, the cautious use of longer acting sulfonylurea
oral agents, or insulin may be safest.
Hepatic Disease
Hepatic disease or insufficiency increases the risks of lactic acidosis and hypoglycemia and influences the
metabolism of many oral medications.
Metformin and thiazolidinediones should not be used if alanine aminotransferase (ALT) is 2.5 to 3 times normal
upper limits.
First generation sulfonylureas, glipizide, and glyburide have some component of hepatic metabolism and should be
used with caution because of the risks of hypoglycemia. Insulin would be considered safest.
20.
Prescribe Insulin Therapy
Insulinprogramsshouldbeindividualizedbasedonthepatient'slifestyle,treatmentgoals,andselfmonitoring blood glucose. Many patients can be taught to interpret self-monitoring blood glucose results and
adjust insulin doses [R]. (See table showing the time course of action of insulin preparations in the original
guideline document.)
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Totaldoserangesfrom5units/daytoseveralhundredunits/day.
Averageinsulindosesare0.6to0.8units/kgofbodyweightperday.
Obesepatientsoftenrequiredosesequaltoorexceeding1.2units/kg.
Mealtimesandsnacksmustbeconsistent.Synchronizeinsulinwithfoodintakepatterns.
Rapid-acting insulin should not be taken more than 15 minutes before meals in contrast to regular insulin,
which should ideally be taken at least 30 minutes before a meal to better match the insulin peak action with
post-meal hyperglycemia.
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Patientswhoaretestingtheirbloodglucosebeforemealsandadjustinginsulindosestomatchmealsmay
find rapid-acting insulin to be more effective although generally studies have not shown an improvement in A1c
when compared to regular insulin taken according to package insert (30 to 45 minutes preprandial).
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Effectiveuseofrapid-acting insulin usually requires the addition of basal intermediate or long-acting insulin.
Thereareseveraldevicesavailableonthemarketfortheadministrationofinsulin(e.g.,insulinpump,insulin
Obesepatientsoftenrequiredosesequaltoorexceeding1.2units/kg.
Mealtimesandsnacksmustbeconsistent.Synchronizeinsulinwithfoodintakepatterns.
Rapid-acting insulin should not be taken more than 15 minutes before meals in contrast to regular insulin,
which should ideally be taken at least 30 minutes before a meal to better match the insulin peak action with
post-meal hyperglycemia.
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Patientswhoaretestingtheirbloodglucosebeforemealsandadjustinginsulindosestomatchmealsmay
find rapid-acting insulin to be more effective although generally studies have not shown an improvement in A1c
when compared to regular insulin taken according to package insert (30 to 45 minutes preprandial).
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Effectiveuseofrapid-acting insulin usually requires the addition of basal intermediate or long-acting insulin.
Thereareseveraldevicesavailableonthemarketfortheadministrationofinsulin(e.g.,insulinpump,insulin
pen).
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Insulinpumptherapymaybehelpfulforpatientswhoareinterestedinmoreintensifiedmanagementof
bloodglucoseandwantmoreflexibility,orifpregnancyisdesired.Candidatesforpumptherapyshouldbe
evaluated by an endocrinologist or diabetes specialist to assess patient understanding, self-care knowledge
including medical nutrition therapy, responsibility, and commitment. Insulin pump therapy is more commonly used
in type 1 patients, but is also being used by some type 2 patients.
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PleasenotetheworkgroupleftthebrandnamesforHumalogand Novologin the table (see the original

guideline document). The generic mix is as follows:
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Humalogmix:lisproprotaminesuspension/lisproinjection
Novologmix:aspartprotaminesuspension/aspartinjection
Everyfacilityneedstoevaluateinsulinsafetypertheirspecificsituation.
22.
Prescribe Non-Insulin Agents
Please consult the manufacturer's product labeling insert for full prescribing information.
If not contraindicated, metformin is the preferred initial oral agent for type 2 diabetes due to low cost, low risk of
hypoglycemia and side effects, and lack of associated weight gain. If metformin is contraindicated, sulfonylureas
and glitazones are acceptable secondary choices for oral agents. Sulfonylureas have the advantage of being
relatively inexpensive, and glitazones are contraindicated in congestive heart failure [R].
Metformin
(See the original guideline document for specific dosage recommendations.)
Efficacy
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TheA1cloweringcommonlyachievedwithmetforminis1.5%to2.0%.
Absorptionandbioavailabilityofmetformin(extendedrelease)2,000mgdailyissimilartothatofmetformin
1,000 mg twice daily. Costs favor the use of metformin for patients who can manage twice-daily dosing.
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Themajoreffectmaybereducinghepaticglucoseproduction.
Metformin is indicated for treatment of type 2 diabetes as monotherapy or in combination with sulfonylureas or
insulin.
Safety
Metforminiscontraindicatedinpatientswithknownhypersensitivity,renaldisease,congestiveheartfailure
(treated with medications), acute or chronic metabolic acidosis (including diabetic ketoacidosis).
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Donotusemetformininrenaldisease(creatininegreaterthanorequalto1.5mg/dLinmencreatinine
greater than or equal to 1.4 mg/dL in women) because of possible lactic acidosis. In patients over age 80, check a
creatinine clearance and use with caution. Even temporary reductions in renal function (e.g., pyelography or
angiography) can cause lactic acidosis.
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Donotuseinpatientswithchronicobstructivepulmonarydisease,severehepaticdisease,oralcoholism.
Sideeffectsmaybetransientandcanincludemetallictaste,diarrhea,nausea,andanorexia.
Theuseofmetformininpregnancyorlactationisnotrecommended.
Asmonotherapy,metformindoesnotcausehypoglycemia.
Intramuscularcontraststudieswithindicatedmaterialscanleadtoacutealterationofrenalfunctionandhave
been associated with lactic acidosis in patients receiving metformin. Therefore, metformin should be temporarily
discontinued at the time or prior to any such study and withheld for 48 hours subsequent to the procedure.
Reinstitute only after renal function has been reevaluated and found to be normal.
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Second-Generation Sulfonylureas
Efficacy
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TheA1cloweringcommonlyachievedwithsulfonylureasis1.5%to2.0%.
Thedoseshouldbeincreasedevery1to2weeksuntilsatisfactoryglycemiccontrolorthemaximumdoseis
reached.
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Therearenomajordifferencesbetweensulfonylureaswithrespecttoeffectivenessincontrolling
hyperglycemia. Switching from one to another is rarely beneficial in improving hyperglycemia.
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Safety
Theseagentsarecontraindicatedindiabeticketoacidosisandinpatientswithknownhypersensitivityto
sulfonylureas.
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Therearerarecross-sensitivities for patients with sulfa allergies.
Theseagentsshouldbeusedwithcautioninpatientswithhepaticorrenaldisease.
Glipizideorglimepiridemayberelativelysaferthanglyburideinpatientswithmildrenalimpairment.
Hypoglycemiariskincreaseswithimpairedrenalfunction.Glimepiridemaycauselesshypoglycemiainthese
circumstances.
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Glyburidehasthehighestrateofhypoglycemiaofthesulfonylureaslisted.
Alpha Glucosidase Inhibitors
sulfonylureas.
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Therearerarecross-sensitivities for patients with sulfa allergies.
Theseagentsshouldbeusedwithcautioninpatientswithhepaticorrenaldisease.
Glipizideorglimepiridemayberelativelysaferthanglyburideinpatientswithmildrenalimpairment.
Hypoglycemiariskincreaseswithimpairedrenalfunction.Glimepiridemaycauselesshypoglycemiainthese
circumstances.
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Glyburidehasthehighestrateofhypoglycemiaofthesulfonylureaslisted.

Efficacy
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TheA1cloweringcommonlyachievedwithalphaglucosidaseinhibitorsis0.5%to1%.
Theseagentsaremostappropriateinpatientswithglucoseandglycosylatedhemoglobinonlymoderately
above goal.
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Theseagentsdelaycarbohydrateabsorption,whichreducespostprandialbloodglucoseandinsulinlevels.
Theseagentsmustbetakenatthebeginningofamealtobeeffective.
Theseagentsareindicatedfortreatmentoftype2diabetesasmonotherapyandascombinationtherapy
(miglitol with sulfonylureas; acarbose with sulphonylureas, metformin, or insulin).
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Safety
Theseagentsarecontraindicatedinpatientswithknownhypersensitivity,serumcreatininelevelsgreaterthan
2 mg/dL, abnormal baseline liver function tests, and inflammatory bowel disease.
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Absorbedmetabolitesofacarbosemayrarelycauseelevatedtransaminaselevels.Monitortransaminaselevels
every 3 months for 1 year, and periodically thereafter.
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Sideeffectsmayincludeabdominalcramping,flatulence,anddiarrhea.Tolerancedevelops,sostartwithlow
dose and increase gradually.
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Asmonotherapy,theseagentsdonotcausehypoglycemia.
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor

Efficacy
Slowstheinactivationofincretins,hormonesthatarenormallyreleasedinthegutthroughoutthedayand
increased after meals. Incretins increase insulin release from pancreatic beta cells, and lower glucagon secretion
from pancreatic alpha cells.
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Indicatedasanadjuncttodietandexercisetoimproveglycemiccontrolinadultswithtype2diabetes
mellitus.
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TheA1Cloweringcommonlyachievedwithsitagliptinis0.6to0.8mg/dL.
Sitagliptinisindicatedformonotherapyandascombinationtherapy(metformin,glimepiride,glimepirideplus
metformin, or a thiazolidinedione [TZD]).
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Sitagliptinhasnotbeenstudiedincombinationwithinsulin.
Canbetakenwithorwithoutfood.
Safety
Dosageadjustmentisrecommendedinpatientswithmoderateorsevererenalinsufficiencyandinpatients
with end stage renal disease (ESRD). Assessment of renal function is recommended prior to initiating sitagliptin
and periodically thereafter.
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Moderaterenaldisease(start50mgoncedaily):CrCl>30 to < 50 mL/min; serum creatinine levels [mg/dL] -men:>1.7to<3.0; women: > 1.5 to <2.5
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SevereandESRD(start25mgoncedaily):CrCl<30mL/min:serumcreatininelevels[mg/dL]-- men: >3.0;

women: >2.5; or on dialysis
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Whenusedwithasulfonylurea,alowerdoseofsulfonylureamayberequiredtoreducetheriskof
hypoglycemia.
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Sideeffectsreportedinmorethan5%ofpatientsandmoreoftenthanplacebowerenasopharyngitis,upper
respiratory tract infections, and headache.
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Safetyandeffectivenessofsitagliptininchildrenunder18yearshavenotbeenestablished.
Therearenoadequateandwell-controlled studies in pregnant women.
Hypoglycemiawassimilartoplacebo(1.2%versus0.9%).
Studiesaddressinglong-term safety are not available.
Meglitinides (Short-Acting Secretagogues)

Efficacy
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TheaverageA1cloweringcommonlyachievedis0.5%.
Themechanismofactionoftheseagentsistostimulateinsulinsecretion(similartosulfonylureas).
Theseagentshaveashortdurationofaction,1to4hours.
Theseagentsareusuallytaken15minutesbeforemeals(rangeof0to30minutes)
TheseagentsareindicatedforuseincombinationwithmetforminorTZDs.
Safety
Themajorsideeffectoftheseagentsishypoglycemiabuttheincidencemaybelesscommonthanwith
sulfonylureas.
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TheaverageA1cloweringcommonlyachievedis0.5%.
Themechanismofactionoftheseagentsistostimulateinsulinsecretion(similartosulfonylureas).
Theseagentshaveashortdurationofaction,1to4hours.
Theseagentsareusuallytaken15minutesbeforemeals(rangeof0to30minutes)
TheseagentsareindicatedforuseincombinationwithmetforminorTZDs.
Safety
Themajorsideeffectoftheseagentsishypoglycemiabuttheincidencemaybelesscommonthanwith
sulfonylureas.
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Skipthedoseifthemealisnoteaten.
Dosesofnateglinideshouldbeadjustedforhepaticimpairment.
Administrationofgemfibrozilsignificantlyincreasesrepaglinidebloodlevels,whichmayleadtohypoglycemia.
Avoid concomitant use of gemfibrozil and repaglinide.
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Glucagon-like Peptide 1 (GLP-1) Agonist

(See the original guideline document for specific dosage recommendations and mechanism of action.)
Efficacy
Intendedforpeoplewithtype2diabeticswhoareonoralmedicationbutarenotachievinggoodbloodsugar
control. Offers an alternative option before starting insulin.
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Mustbeadministeredwithinthe60-minutes before the morning and evening meals. It should not be

administered after a meal.
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Whenthisagentisaddedtosulfonylureatherapy,areductioninthedoseofsulfonylureamaybeneededto
reduce the risk of hypoglycemia.
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Advantagesoverinsulinareyetunclear,sincelikeinsulin,itmustbeinjectedtwicedaily.
ImprovesA1cbyanaverageof0.9%andlowerspostprandialglucose.
Safety
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Contraindicatedinpatientswithknownhypersensitivitytothisproductoranyofitscomponents.
Itisnotasubstituteforinsulinininsulin-requiring patients.
Shouldnotbeusedinpatientswithtype1diabetesorforthetreatmentofdiabeticketoacidosis.
NotrecommendedforuseinpatientswithESRDorsevererenalimpairment(CrCllessthan30mL/min).
Notrecommendedinpatientswithseveregastrointestinaldiseasebecauseitsuseiscommonlyassociated
with gastrointestinal adverse effects, including nausea, vomiting, and diarrhea.
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Cautioninpatientsreceivingoralmedicationsthatrequirerapidgastrointestinalabsorption.
Fororalmedicationsthataredependentonthresholdconcentrationsforefficacy,suchascontraceptivesand
antibiotics, patients should be advised to take those drugs at least 1 hour before exenatide injection.
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Weightlossisoftenassociatedwithuseofthisagent,especiallywhenusedconcomitantlywithmetformin.
Exenatideusehasbeenassociatedwithreportsofpancreatitis,althoughacausalrelationshiphasnottothis
point been established.
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Synthetic Analog of Human Amylin

(See the original guideline document for specific dosage recommendations and mechanism of action.)
Efficacy
Indicatedasanadjuncttreatmentinpatientswithtype1ortype2diabeteswhousemealtimeinsulintherapy
and who have failed to achieve desired glucose control despite optimal insulin therapy, and it is used with or
without a sulfonylurea and/or metformin.
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MaydecreasesA1cbyanaverageof0.4%andmayobserveweightlossoflessthan1kgatsixmonths.
Mustbeadministeredimmediatelypriortoeachmajormeal.
Reducepreprandial,rapid-acting or short-acting insulin dosages, including fixed-mix insulins by 50%.
Theagentmaybeconsideredinhighlymotivatedpatientswillingtoaddtwotofourinjectionsandmore
frequent glucose monitoring to their regimen.
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Safety
l
Contraindicatedinpatientswithaknownhypersensitivitytoanyofitscomponents,includingmetacresol.
Shouldonlybeconsideredinpatientswithinsulin-using type 2 or type 1 diabetes who have failed to achieve

adequate glycemic control despite individualized insulin management and are receiving ongoing care under the
guidance of a health care professional skilled in the use of insulin and supported by the services of diabetes
educator(s).
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Beforeinitiationoftherapy,A1c,recentglucosemonitoringdata,historyofinsulin -induced hypoglycemia,

current insulin regimen, and body weights should be reviewed.
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Patientsmeetinganyofthefollowingcriteriashould not be considered for pramlintide therapy:

l
Pooradherencewithcurrentinsulinregimen
Pooradherencewithprescribedself-blood glucose monitoring
A1cgreaterthan9%
Recurrentseverehypoglycemiarequiringassistanceduringthepastsixmonths
Presenceofhypoglycemiaunawareness
Confirmeddiagnosisofgastroparesis
Requiretheuseofdrugsthatstimulategastrointestinalmotility
Requiretheuseofdrugsthatslowtheintestinalabsorptionofnutrients
Pediatricpatients
Pooradherencewithprescribedself-blood glucose monitoring
A1cgreaterthan9%
Recurrentseverehypoglycemiarequiringassistanceduringthepastsixmonths
Requiretheuseofdrugsthatstimulategastrointestinalmotility
Requiretheuseofdrugsthatslowtheintestinalabsorptionofnutrients
Pediatricpatients
Pramlintidealonedoesnotcausehypoglycemia(withouttheconcomitantadministrationofinsulin).However,
when it is co-administered with insulin therapy, there is an increase risk of insulin-induced severe hypoglycemia.
Therefore, prescribe frequent pre- and postmeal glucose monitoring combined with an initial 50% reduction in
premeal doses of short-acting insulin when starting pramlintide to reduce the occurrence of hypoglycemia.
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Itsuseiscommonlyassociatedwithgastrointestinaladverseeffects,includingnausea,anorexiaandvomiting.
Whentherapidonsetofaconcomitantorallyadministeredagentisacriticaldeterminantofeffectiveness,the
agent should be administered at least one hour prior to two hours after pramlintide injection.
l
Thisproductandinsulinshouldalwaysbeadministeredasseparateinjectionsandneverbemixed.Mixingwill
alter the pharmacokinetics parameters of pramlintide.
l
Thiazolidinediones (TZDs)
Efficacy
l
TheA1cloweringcommonlyachievedwiththiazolidinedionesis1.0%to1.5%.
TZDsimproveinsulinactioninperipheraltissues,particularlymuscle.
Bothpioglitazoneandrosiglitazoneareindicatedforcombinationtherapywithsulfonylureas,metformin.
BothLDLandHDLcholesterolconcentrationsmayincreaseslightly.
Rosiglitazonemayincreasecardiovasculareventsandisnotrecommended.
Whenathiazolidinedioneisused,pioglitazoneispreferredduetoconcernsaboutrosiglitazonecardiovascular
safety in observational analysis.
l
Safety
TZDsarecontraindicatedinpatientswithknownhypersensitivity.Theiruseinpregnancyandlactationisnot
recommended.
l
TZDs,aloneorincombinationwithotherantidiabeticagents,includinginsulin,cancausefluidretention,
which may lead to heart failure. Do not use in patients with moderate to severe heart failure (New York Heart
Association Class III and IV cardiac status).
l
Sideeffectsmayincludemoderateweightgain,edema,andmildanemia,alldueatleastinpart,tofluid
retention.
l
Asmonotherapy,TZDsdonotcausehypoglycemia.
MeasureALTatbaselineandperiodicallythereafter.
Administrationofgemfibrozilincreasesplasmalevelsofrosiglitazone.Decreasesinthedoseofrosiglitazone
may be needed when gemfibrozil is added.
l
Meta-analysis showed rosiglitazone may be associated with an increase in the risk of myocardial infarction and
death from cardiovascular causes.
l
Pioglitazonemaynothavethesamecardiovascularconcernsasrosiglitazone[R].
Macularedemahasbeenreportedinpostmarketingexperienceinsomediabeticpatientswhoweretaking
thiazolidinedione.
l
Theriskoffractureshouldbeconsideredinthecareofpatients,especiallyfemalepatients,treatedwith
thiazolidinedione.
l
Physiciansandpatientsshouldhaveaninformeddiscussionaroundtherisksofrosiglitazone.
Combination Products
(See the original guideline document for specific dosage recommendations for the following combinations:
sulfonylurea + metformin, TZD + metformin, TZD + sulfonylureas, DDP-IV inhibitor + metformin).
25.
Intensify Therapy
If treatment goals are not met on oral agents, or if oral agents are contraindicated, then it is necessary to begin
insulin either alone or as an adjunct to oral therapy. There are many regimens that have been studied and are
efficacious [A], [R]. The following commonly used regimens are discussed in the original guideline document:
insulin as an adjunct to oral therapy, insulin alone, and oral agents as an adjunct to insulin therapy.
Blood Pressure Control Algorithm Annotations
26.
Blood Pressure Control Algorithm
Control of blood pressure is at least as important as glycemic control for people with type 2 diabetes in reducing
the risk of complications [A], [B].
27.
Is Systolic Blood Pressure Greater Than or Equal to 130 mm Hg?
For patients with Type 2 diabetes mellitus, the systolic blood pressure goal is less than 130 mm Hg and the
diastolic blood pressure goal is less than 80 mm Hg. [Conclusion Grade II: See Conclusion Grading Worksheet D Annotation #13, 14, 27, 29 (goals for Blood Pressure) in the original guideline document] [A].
A report from the UK Prospective Diabetes Study showed an inverse relationship between systolic blood pressure
and the aggregate end point for any complication related to diabetes [R]. The lowest risk occurred at a systolic
blood pressure below 120 mm Hg.
The goal for patients with renal insufficiency and urinary protein excretion greater than 1 to 2 g/day should be less
than 120/75 mm Hg [R].
27.
Is Systolic Blood Pressure Greater Than or Equal to 130 mm Hg?
For patients with Type 2 diabetes mellitus, the systolic blood pressure goal is less than 130 mm Hg and the
diastolic blood pressure goal is less than 80 mm Hg. [Conclusion Grade II: See Conclusion Grading Worksheet D Annotation #13, 14, 27, 29 (goals for Blood Pressure) in the original guideline document] [A].
A report from the UK Prospective Diabetes Study showed an inverse relationship between systolic blood pressure
and the aggregate end point for any complication related to diabetes [R]. The lowest risk occurred at a systolic
blood pressure below 120 mm Hg.
The goal for patients with renal insufficiency and urinary protein excretion greater than 1 to 2 g/day should be less
than 120/75 mm Hg [R].
28.
Treat Systolic Blood Pressure to Less Than 130 mmHg. While ACE Inhibitors and ARBs Are Preferred FirstLine Therapy, Two or More Agnes (to Include Thiazide Diuretics) May Be Required
Non-pharmacologic and pharmacologic methods are recommended at blood pressures greater than or equal to
130/80 mm Hg. The initial focus of treatment should be the systolic blood pressure.
For patients with type 2 diabetes mellitus, ACE inhibitors or ARBs can reduce progression of micro- and
macrovascular complications. [Conclusion Grade I: See Conclusion Grading Worksheet F -- Annotations #28, 36
(Treatment with ACE Inhibitors or ARBs) in the original guideline document] [A].
While ACE inhibitors and ARBs are preferred first-line therapy, two or more agents (to include thiazide diuretics)
may be required. For patients with type 2 diabetes mellitus, thiazide diuretics in the treatment of hypertension can
reduce cardiovascular events, particularly heart failure. [Conclusion Grade I: See Conclusion Grading Worksheet G -Annotations #28, 36 (Thiazide Diuretics) in the original guideline document] [A], [B]. The possible advantages to
ACE inhibitors include renal protection, decreased insulin resistance, lack of adverse effect on lipids, and decreased
cardiovascular risk.
Treatment of isolated systolic hypertension, as well as combined systolic and diastolic hypertension, in both young
and elderly people protects against major cardiovascular diseases. Drug treatment should be initiated if systolic
blood pressure is greater than or equal to 130 mm Hg [R].
Thiazide diuretics used in the treatment of hypertension can reduce cardiovascular events, especially heart failure,
for patients with type 2 diabetes [A], [D], [R]
29.
Is Diastolic Blood Pressure Less Than 80 mm/Hg?
diastolic blood pressure goal is less than 80 mm Hg [Conclusion Grade II: See Conclusion Grading Worksheet D -Annotations #13, 14, 27, 29 (Goals for Blood Pressure) in the original guideline document] [A].
The Hypertension Optimal Treatment (HOT) trial provides evidence that a target diastolic blood pressure less than
80 mm Hg has a cardioprotective effect in people with diabetes. This study reported that in the diabetic subgroup
(n=1,501) major cardiovascular events were reduced by greater than 51% (p=0.005) in those randomized to a
diastolic blood pressure goal of less than 80 mm Hg compared to less than 90 mm Hg. The HOT study has been
criticized by some because this was a post hoc analysis of a subgroup of patients in the study and the number of
events is relatively small. Nevertheless, results are consistent with UKPDS. UKPDS achieved an average diastolic
blood pressure of 82 mm Hg in the tightly controlled group (vs. 87 mm Hg in the less tightly controlled group). The
more tightly controlled group had diabetes related end points reduced by 24% (p=0.005) and death by 32%
(p=.019) [A].
31.
Treat Diastolic Blood Pressure to Less Than 80 mm Hg
Combinations of medications are often required to achieve goals. Thirty percent of patients in the tight blood
pressure arm of the UKPDS with goal less than 150/85 mm Hg required 3 or more antihypertensive medications to
achieve the mean 144/82 mm Hg. Findings from the ALLHAT study suggest that thiazide diuretics be considered as
part of a multi-drug regimen [A], [M].
Ongoing Management Algorithm Annotations
33.
Ongoing Management and Follow-Up of People with Diabetes
In studies of general population groups, coronary artery disease deaths have been substantially reduced by the
treatment of hypertension, hypercholesterolemia and smoking. Lipid treatment has also been shown to be of
benefit in diabetes. Therefore, risk factor reduction is prudent for patients with diabetes [A], [R].
Frequencyofvisitsdependsonbloodglucosecontrol,changesinthetreatmentregimen,andpresenceof
complications of diabetes or other medical conditions.
l
Patientsstartingorhavingamajorchangeintheirtreatmentprogram(suchasinitiatinginsulintherapy)may
need to be in contact with their care provider as often as daily until glucose control is achieved, the risk of
hypoglycemia is low, and the patient is competent to conduct the treatment program.
l
Contactwiththepatientafteramajormodificationofthetreatmentplan(suchasintroducinganew
medication) should not be delayed greater than 1 week.
l
Regularvisitsshouldbescheduledforinsulin-treated patients at least quarterly and for other patients at

least semiannually. More frequent visits may be necessary if treatment goals are not achieved.
l
Cardiovasculardiseaseistheprimarycauseofmorbidityandmortalityinpeoplewithtype2diabetes.Therisk
of coronary artery disease is approximately doubled in men and quadrupled in women with diabetes.
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Ateachencounter,askifthepatienthasexperiencedsymptomsofhypoglycemiaorlowbloodglucose,and
educate the patient on appropriate recognition, prevention, and management
l
Ifthepatienthasahistoryofseverehypoglycemia(assistanceofanotherpersonwasneededtotreatalow
glucose) or has developed hypoglycemia unawareness, evaluate the treatment goals for appropriate safety.
l
34.
Maintain Treatment Goals
l
Nutrition/physicalactivity:workwithindividualpatientsregularlytosetrealisticgoals.
MonitorA1cevery3to6months.Ininsulintreatedpatientsandnon-insulin-treated patients with poor

metabolic control, quarterly A1c may assist management.
l
Reviewbloodglucoseatallpatientencounters.Reinforcebloodglucosetargetswithpatientsandeducate
regarding hypoglycemia.
l
Monitorlipidprofileyearly(totalcholesterol,triglycerides,HDLandLDLcholesterol).Treattoachieve
recommended goals. (See Annotation #13, "Treatment Goals for Patients without Cardiovascular Disease"). If
lipid goals are consistently met, patient is in metabolic control, has stable clinical conditions, and has not had a
change in medication, an annual lipid profile is not mandatory.
l
34.
Maintain Treatment Goals
l
Nutrition/physicalactivity:workwithindividualpatientsregularlytosetrealisticgoals.
MonitorA1cevery3to6months.Ininsulintreatedpatientsandnon-insulin-treated patients with poor

metabolic control, quarterly A1c may assist management.
l
Reviewbloodglucoseatallpatientencounters.Reinforcebloodglucosetargetswithpatientsandeducate
regarding hypoglycemia.
l
Monitorlipidprofileyearly(totalcholesterol,triglycerides,HDLandLDLcholesterol).Treattoachieve
recommended goals. (See Annotation #13, "Treatment Goals for Patients without Cardiovascular Disease"). If
lipid goals are consistently met, patient is in metabolic control, has stable clinical conditions, and has not had a
change in medication, an annual lipid profile is not mandatory.
Diabetes is a major risk factor for coronary artery disease, and many patients with diabetes also have lipid
disorders [R]. Thus, control of dyslipidemia in diabetes is important because evidence shows that correcting lipid
disorders reduces the rate of coronary artery disease events.
l
Monitorbloodpressureeachvisitandcontrolhypertensiontorecommendedlevels.SeetheBlood Pressure
Control algorithm annotations.
l
Askaboutaspirinuseandrecommendaspirinuseinpatientsage40andoverunlesscontraindicated[R].
Askaboutalcoholandtobaccouseandassistwithcessationifindicated.
35.
Annual Assessment of Complications
Targeted Annual History and Physical Exam
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Thehistoryshouldassess[R]:
Resultsofselfmonitoringbloodglucosevalidateresultsatleastonceayear(i.e.,checkpatient'sglucose
meter against an office random capillary glucose)
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Adjustmentsbythepatientofthetherapeuticregimen
Frequency,causes,andseverityofbothhyperglycemiaandhypoglycemia
Problemswithadherencetotherapeuticregimen
Symptomssuggestingdevelopmentorprogressionofthecomplicationsofdiabetes
Currentprescribedmedicationsover-the-counter medications, dietary supplements and alternative therapies
Documentationofeyecarespecialistexamresults
Alcohol/drugusepatterns
Assessforsymptomsofdepression
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Labassessmentofliverfunctionand/orcreatininetoassessongoingacceptabilityofmedicationusage
Thetargetedphysicalexamshouldassess:
l
Weight,bodymassindex(BMI)
Bloodpressure
Cardiovascular- evaluation of preexisting problems
Feet(nails,webspaces,calluses,ulcers,structuraldeformities,protectivesensationandshoes)
Specialist Dilated Eye Exam

A dilated eye examination for diabetic eye disease performed by an ophthalmologist or optometrist is recommended
annually for patients with type 2 diabetes mellitus [R]. Less frequent exams (every two to three years) may be
considered in the setting of a normal eye exam.
Renal Assessment
Urinary albumin excretion should be tested annually by a microalbuminuria method. There are racial/ethnic
variability with regard to the prevalence of end-stage renal disease with Native Americans, Latinos (especially
Mexican Americans), and African Americans having higher rates than non-Hispanic whites with type 2 diabetes [R].
Ifalbuminuriaisabovenormal,serumcreatinineshouldbemeasured.Screeningformicroalbuminuriacanbe
performed by three methods [B], [R]:
Measurementofthealbumin-to-creatinine ratio in a random, spot collection. This is easiest to perform,
generally accurate and therefore is the preferred screening method.
l
24-hour collection with creatinine, allowing for simultaneous measurement of creatinine clearance
Timed(four-hour or overnight) collection
Some factors can artificially increase the levels of albumin in the urine and should be avoided at the time of the
urine collection; these factors include blood in the urine, prolonged heavy exercise, fever, congestive heart failure,
uncontrolled diabetes, severe hypertension, urinary tract infection, and vaginal fluid contamination of specimen.
If the dipstick or urine analysis test is negative for protein, then a more sensitive early screening test is indicated.
A qualitative urinary microalbumin screen can be used to detect urinary microalbumin. If the qualitative test is
positive, a quantitative test must be performed.
A microalbumin screening test should be done each year on patients with type 2 diabetes. If positive (exceeds 30
mg/g), it should be repeated twice in the next 3 months.
If 2 out of 3 of these screening microalbuminuria tests are positive, the individual has microalbuminuria and
interventions should be considered. A negative finding should be followed yearly; a positive finding should be
followed periodically to see if the interventions are effective in diminishing the albuminuria [R].
See Appendix A, "Treatment of Diabetic Nephropathy, " in the original guideline document.
Comprehensive Foot Exam with Risk Assessment
Patients with one or more risk factors for foot complications should be educated about their risk factors and
appropriate measures taken to avoid complications. Measures may include self-management education, more
intensive follow-up, and/or referral to appropriate specialist [R].
Risk factors for foot complications include:
Lossofprotectivesensation.Protectivesensationcanbeassessedusingeithera5.07Semmes-Weinstein
monofilament for light touch or by testing vibration using a 128-Hz tuning fork at the dorsum of the
interphalangeal joint of the great toe, or both. Patients with reduced or absent sensation with either of these
l
See Appendix A, "Treatment of Diabetic Nephropathy, " in the original guideline document.
Comprehensive Foot Exam with Risk Assessment
Patients with one or more risk factors for foot complications should be educated about their risk factors and
appropriate measures taken to avoid complications. Measures may include self-management education, more
intensive follow-up, and/or referral to appropriate specialist [R].
Risk factors for foot complications include:
Lossofprotectivesensation.Protectivesensationcanbeassessedusingeithera5.07Semmes-Weinstein
monofilament for light touch or by testing vibration using a 128-Hz tuning fork at the dorsum of the
interphalangeal joint of the great toe, or both. Patients with reduced or absent sensation with either of these
tests should be educated about their risk and the need for proper foot care to prevent foot complications. (See
Appendix B, "Using a Semmes-Weinstein Monofilament to Screen the Diabetic Foot for Peripheral Sensory
Neuropathy" in the original guideline document)
l
Peripheralvasculardisease(absentpedalpulse,historyofclaudication,orischemicskinchanges)
Structuraldeformities(bunion,hammertoes,Charcotdeformity,limitedjointmobility,orprioramputation)
Skindisorders(naildeformity,callus,fissure,tinea,orulceration)
Footwear(excessivelyworn,illfitting,orinappropriateshoes)
Cardiovascular and Cerebrovascular Complication Assessment

l
Historyofcardiovascularsymptomssuchaschestpain,vascularclaudication,transientischemicattack(TIA)
Cardiacandcarotidexams
Evaluatecardiovascularstatusbeforeadvisingincreasedintensityofexercise[R]
Special Considerations
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Influenzavaccineeveryyear
Pneumococcalvaccine- consider repeating the immunization for those at risk of losing immunity after five
years including:
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Nephroticsyndrome
Chronicrenaldisease
Otherimmunocompromisedstates
ThereisevidencethatACEinhibitorsandARBsarebeneficialinreducingcardiovascularmorbidityand
mortality in acute myocardial infarction, congestive heart failure, and type 2 diabetes patients at high risk for
cardiovascular disease; they are also beneficial in improving renal outcomes in diabetes. Results of the HOPE
(Heart Outcomes Prevention Evaluation) study strongly support the use of ACE inhibitors for patients with
diabetes who are at high risk for cardiovascular disease. In the Second Australian National Blood Pressure Study
(ANBP2), the use of ACE inhibitors in older patients was associated with better cardiovascular outcomes, despite
similar reductions in blood pressure from diuretics. Confirming studies would be helpful to strengthen this
recommendation or to generalize recommendations to all patients with diabetes [A].
l
VitaminEhasnoapparenteffectoncardiovascularoutcomes[A].
Osteoporosis:Type2diabetesdoesnotappeartobeariskfactorfordecreasedbonemineraldensity
nonetheless, some studies have found an increased fracture risk for people with type 2 diabetes [B].
Hypoglycemic episodes, decreased visual acuity secondary to retinopathy, and altered balance and postural
control secondary to peripheral and autonomic neuropathy can all increase the risk of falls and fracture.
In the absence of diabetes specific osteoporosis screening guidelines, it is reasonable to follow general
osteoporosis screening recommendations for people with diabetes. See the NGC summary of the ICSI
guidelineDiagnosis and Treatment of Osteoporosis for more information.
l
36.
Treatment and Referral for Complications
Nephropathy
In type 2 diabetes, albuminuria may be present at the time of diagnosis in about 10% of patients, and another
10% later develop it. Progression to renal failure is less certain in type 2 patients than in type 1 patients, and
appears to be modulated by genetic and other factors.
Patients with clinical nephropathy almost always have retinopathy and coronary artery disease.
Numerous interventions are appropriate at different stages of renal function in order to prevent or slow the
progression of renal disease and associated cardiovascular disease and include [R]:
GlucoseControl- Improved glucose control at any stage of renal function reduces renal disease progression.
See the Glycemic Control algorithm.
l
Forpatientswithtype2diabetesmellitus,ACEInhibitorsandARBscanreduceprogressionofmicro - and
macroalbuminuria complications. [Conclusion Grade I: See Conclusion Grading Worksheet F Annotations #28, 36
(Treatment with ACE Inhibitors or ARBs) in the original guideline document] [A]. These agents appear effective
even in normotensive microalbuminuric individuals. This class of drugs must not be used in pregnancy. Within one
week of initiation, check for elevations in potassium and creatinine levels and monitor for cough.
l
HypertensionControl- Although ACE inhibitors and ARBs seem to have special renal protective properties
beyond their antihypertensive effect, any effort to optimize blood pressure will help the kidneys. When significant
microalbumin or overt nephropathy is present, there may be a tendency to retain sodium. In this case, a loop
diuretic added to the antihypertensive regimen is often helpful. A goal blood pressure of 130/80 mm Hg is
recommended [R]. See the Blood Pressure Control algorithm annotations.
For patients with type 2 diabetes, thiazide diuretics in the treatment of hypertension can reduce cardiovascular
events, particularly heart failure. [Conclusion Grade I: See Conclusion Grading Worksheet G -- Annotations #28,
36 (Thiazide Diuretics) in the original guideline document] [A], [B].
In ALLHAT, chlorthalidone, at doses of 12.5-25 mg daily, was superior to other treatments at reducing
cardiovascular events in both diabetic and non-diabetic patients.
l
CardiovascularRiskFactorIntervention- Dyslipidemia is often present with microalbuminuria and should be

treated aggressively. Dyslipidemia may be an independent risk factor for progression of renal disease. Smoking is
associated with the onset and progression of microalbuminuria.
l
Restrictionofdietaryproteinhasbeenshowntoslowprogressionofovertnephropathy(macroalbuminuria),
and there may be some benefit in dietary protein reduction in microalbuminuric patients. In these circumstances,
protein intake should be reduced to the adult recommended daily allowance (RDA) of 0.8 to 1.0 g/kg body weight
l
For patients with type 2 diabetes, thiazide diuretics in the treatment of hypertension can reduce cardiovascular
events, particularly heart failure. [Conclusion Grade I: See Conclusion Grading Worksheet G -- Annotations #28,
36 (Thiazide Diuretics) in the original guideline document] [A], [B].
In ALLHAT, chlorthalidone, at doses of 12.5-25 mg daily, was superior to other treatments at reducing
cardiovascular events in both diabetic and non-diabetic patients.
CardiovascularRiskFactorIntervention- Dyslipidemia is often present with microalbuminuria and should be
treated aggressively. Dyslipidemia may be an independent risk factor for progression of renal disease. Smoking is
associated with the onset and progression of microalbuminuria.
l
Restrictionofdietaryproteinhasbeenshowntoslowprogressionofovertnephropathy(macroalbuminuria),
and there may be some benefit in dietary protein reduction in microalbuminuric patients. In these circumstances,
protein intake should be reduced to the adult recommended daily allowance (RDA) of 0.8 to 1.0 g/kg body weight
per day with microalbuminuria present, and 0.8 gm/kg body weight per day with macroalbuminuria present [R].
Treatment for microalbuminuria includes aggressive blood pressure control, glycemic control, ACE inhibitor or ARB
use, and aggressive cardiovascular risk factor screening and management. Strongly consider referral to nephrology
any patients with a creatinine greater than 1.5 mg or nephrotic range proteinuria (greater than 3 g/24 hr).
Nephrology interventions often include early patient education as renal disease progresses, review and
reinforcement of the medical regimen, and preservation of arm veins for future vascular access. Patients with a
creatinine clearance of less than 30 mL/min should be referred to nephrology for discussions of future options and
to enhance the ability to receive a future transplant. These patients also have significant enough renal
impairment that they also benefit from more intensive nutritional interventions and proper management of
anemia and bone disease. See the Blood Pressure Control algorithm [A], [B], [R].
l
Neuropathy - Peripheral neuropathy is difficult to prevent and treat. Most patients with type 2 diabetes and
peripheral neuropathy have few symptoms but are found on examination to have diminished reflexes and sensation.
Sometimes neuropathy can be very painful, especially at night, with "pins-and-needles" numbness and tingling in a
stocking-and-glove distribution. Absence of reflexes or decreased thermal, vibratory, proprioceptive or pain
sensation may be noted on examination and confirm the diagnosis. Good glycemic control should be the first control
to symptomatic neuropathy. Treatment with amitriptyline, nortriptyline, or trazodone in doses beginning at 25 mg
at night and increasing to 75 mg may help some patients. Topical treatment with capsaicin, 0.025% cream three to
four times per day, has also shown benefit. Carbamazepine, duloxetine, and gabapentin may also improve
neuropathic pain. These medications may provide symptomatic relief, but they do not improve the neuropathy [R].
Retinopathy - Prevalence of retinopathy is related to the duration of diabetes mellitus. After 20 years of diabetes
mellitus more than 60% of patients have some degree of retinopathy [R]. Diabetic retinopathy is estimated to be
the most frequent cause of new cases of blindness among adults ages 20 to 74 years.
Up to 21% of patients with type 2 diabetes mellitus are found to have retinopathy at the time of diagnosis of
diabetes mellitus [R]. Generally retinopathy progresses from mild background abnormalities to preproliferative
retinopathy to proliferative retinopathy.
Poor glucose control is associated with progression of retinopathy. High blood pressure is a risk factor for the
development of macular edema and is associated with the development of proliferative retinopathy [R].
Screening for diabetic retinopathy saves vision at a relatively low cost. In fact, screening costs may be less than
the costs of disability payments for those that go blind. Laser photocoagulation surgery is effective in preventing
visual loss in diabetic retinopathy.
Studies have shown that retinal examinations by physicians who are not eye care specialists are not reliable in
detecting retinopathy [A], [C], [R].
Treatment includes glycemic and blood pressure control. Periodic screening and dilated eye exams by an eye
specialist and early treatment of diabetic retinopathy prevents visual loss [R]. See the Glycemic Control and Blood
Pressure Control algorithms.
Cardiovascular and Cerebrovascular disease - Treatment includes control of cardiovascular risk factors
(hypertension, hyperlipidemia, and smoking cessation) and aspirin use. Consider referring patients with known
coronary artery disease to cardiology and patients with known carotid disease to surgery.
Heart failure is also common in patients with diabetes. Caution should be used when prescribing spironolactone and
eplerenone to people with diabetes, especially in combination with ACE inhibitors.
Close monitoring of potassium and renal function is necessary. Thiazolidinediones must also be used with caution
in patients with Class I and II congestive heart failure or patients at high risk for congestive heart failure. Close
monitoring for fluid retention and signs of congestive heart failure is needed. Thiazolidinediones should not be used
in Class III and IV congestive heart failure.
For patients with type 2 diabetes mellitus, thiazide diuretics in the treatment of hypertension can reduce
cardiovascular events, particularly heart failure. [Conclusion Grade I: See Conclusion Grading Worksheet G -Annotations #29, 36 (Thiazide Diuretics) in the original guideline document] [A].
Patients with type 2 diabetes have twice the average risk of suffering a stroke [R]. It is unclear whether good
glycemic control reduces this risk. However, treatment of hypertension, smoking, and hyperlipidemia reduces the
risk of stroke in most persons. See Annotation #14, "Treatment Goals for Patients with Cardiovascular Disease" and
the Blood Pressure Control algorithm annotations.
Peripheral vascular disease - Peripheral arterial disease is commonly associated with diabetes [R]. As many as
36% of patients with diabetes have lower-extremity peripheral arterial disease based on lower-extremity blood
pressure readings. However, a typical history of intermittent claudication or an absent peripheral pulse is less
commonly noted.
Peripheral vascular disease in combination with peripheral neuropathy places patients with diabetes at increased
risk for non-traumatic amputations of the lower extremity. Peripheral vascular disease may be slowed by smoking
cessationandtreatmentofhypertensionanddyslipidemia.(SeeAnnotation#14"TreatmentGoalsforPatients
with Cardiovascular Disease" and the Blood Pressure Control algorithm annotations).
Aggressive daily foot care, inspection of the feet at every office visit, early treatment of foot infections, treatment
of callus, use of moisturizing lotion, and proper footwear may forestall problems, including amputation. Vascular
surgery may also prevent amputation in some patients with established severe peripheral vascular disease [R].
Proper high-risk foot management is necessary to prevent ulceration and amputation. Consider referral of patients
with claudication and/or absent pedal pulses to surgery. Vascular surgery may prevent amputation in some patients
with severe peripheral vascular disease. See the Glycemic Control and Blood Pressure Control algorithms.
Definitions:
Aggressive daily foot care, inspection of the feet at every office visit, early treatment of foot infections, treatment
of callus, use of moisturizing lotion, and proper footwear may forestall problems, including amputation. Vascular
surgery may also prevent amputation in some patients with established severe peripheral vascular disease [R].
Proper high-risk foot management is necessary to prevent ulceration and amputation. Consider referral of patients
with claudication and/or absent pedal pulses to surgery. Vascular surgery may prevent amputation in some patients
with severe peripheral vascular disease. See the Glycemic Control and Blood Pressure Control algorithms.
Definitions:
Conclusion Grades:
Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The
results are both clinically important and consistent with minor exceptions at most. The results are free of any
significant doubts about generalizability, bias, and flaws in research design. Studies with negative results have
sufficiently large samples to have adequate statistical power.
Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but
there is some uncertainty attached to the conclusion because of inconsistencies among the results from the studies or
because of minor doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively,
the evidence consists solely of results from weaker designs for the question addressed, but the results have been
confirmed in separate studies and are consistent with minor exceptions at most.
Grade III: The evidence consists of results from studies of strong design for answering the question addressed, but
there is substantial uncertainty attached to the conclusion because of inconsistencies among the results of different
studies or because of serious doubts about generalizability, bias, research design flaws, or adequacy of sample size.
Alternatively, the evidence consists solely of results from a limited number of studies of weak design for answering the
question addressed.
Grade Not Assignable: There is no evidence available that directly supports or refutes the conclusion.
Study Quality Designations
The quality of the primary research reports and systematic reviews are designated in the following ways on the
conclusion grading worksheets:
Positive: indicates that the report or review has clearly addressed issues of inclusion/exclusion, bias, generalizability,
and data collection and analysis.
Negative: indicates that these issues (inclusion/exclusion, bias, generalizability, and data collection and analysis)
have not been adequately addressed.
Neutral: indicates that the report or review is neither exceptionally strong nor exceptionally weak.
Not Applicable: indicates that the report is not a primary reference or a systematic review and therefore the quality
has not been assessed.
Classes of Research Reports:
A.PrimaryReportsofNewDataCollection:
Class A:
l
Randomized,controlledtrial
Class B:
l
Cohortstudy
Class C:
l
Case-control study
Class D:
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Caseseries
Casereport
B.ReportsthatSynthesizeorReflectuponCollectionsofPrimaryReports:
Class M:
l
Meta-analysis
Systematicreview
Decisionanalysis
Cost-effectiveness analysis
Class R:
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Consensusstatement
Consensusreport
Narrativereview
Class X:
l
Medicalopinion
Clinical Algorithm(s)
Four detailed and annotated clinical algorithms are provided for:
Consensusstatement
Consensusreport
Narrativereview
Class X:
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Medicalopinion
Clinical Algorithm(s)
Four detailed and annotated clinical algorithms are provided for:
l
Diagnosis and Management of Type 2 Diabetes Mellitus
Glycemic Control
Blood Pressure Control
Ongoing Management
Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations
The type of supporting evidence is classified for selected recommendations (see "Major Recommendations").
In addition, key conclusions contained in the Work Group's algorithms are supported by a grading worksheet that
summarizes the important studies pertaining to the conclusion. The type and quality of the evidence supporting these
key recommendations (i.e., goal for glycemic control; goal for LDL level; goals for blood pressure, aspirin use, and
treatment with angiotensin converting enzyme [ACE] inhibitors or angiotensin II receptor blockers [ARBs]) is graded for
each study.
Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
Effective medical management of prediabetes and type 2 diabetes mellitus through a comprehensive approach that
includes nutrition therapy, physical activity recommendations, pharmacologic therapy, self-management, as well as
prevention and diagnosis of diabetes-associated complications and risk factors
Potential Harms
l Theactionofinsulin preparations is highly variable among individuals, with values varying depending on the site
and depth of injection, skin temperature, and exercise.
l
OralagentsdonothaveU.S.FoodandDrugAdministration(FDA)approvalforuseinpregnancy.
Hypoglycemiaisariskinindividualswhoparticipateinphysical activity and are taking insulin, sulfonylureas

and/or meglitinides. Depending on the level of physical activity, the medication dosage or the amount of
carbohydrate ingested, hypoglycemia can occur. For patients on these drug classes and pre-exercise glucose monitor
results less than 100 mg/dL, additional carbohydrate should be ingested for prevention of hypoglycemia.
l
Refer to the "Safety" sections of the "Major Recommendations" for safety information on specific non-insulin agents.
Contraindications
Contraindications
Sulfonylureas
l
Diabeticketoacidosis
Hypersensitivitytosulphonylureas
Metformin
l
Hypersensitivity,acuteorchronicmetabolicacidosis(includingdiabeticketoacidosis)
Renaldisease(creatinine>1.5 mg/dL in men, >1.4 mg/dL in women)
Chronicobstructivepulmonarydisease(COPD),congestiveheartfailure(treatedwithmedication),severehepatic
disease, or alcoholism
l

l
Serumcreatininelevelsgreaterthan2mg/dL
Abnormalbaselineliverfunctiontests
Inflammatoryboweldisease
Hypersensitivity
Thiazolidinediones
l
Hypersensitivity
Moderatetosevereheartfailure(NewYorkHeartAssociation[NYHA]ClassIIIandIVcardiacstatus)
Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin II Receptor Blockers (ARBs)

l
Pregnancy
Glucagon-like Peptide 1 Agonist

l
Hypersensitivity
Type1diabetes
Treatmentofdiabeticketoacidosis
Moderatetosevereheartfailure(NewYorkHeartAssociation[NYHA]ClassIIIandIVcardiacstatus)
Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin II Receptor Blockers (ARBs)

l
Pregnancy
Glucagon-like Peptide 1 Agonist

l
Hypersensitivity
Type1diabetes
Treatmentofdiabeticketoacidosis
Synthetic Analog of Human Amylin

l
Hypersensitivity
Poorcompliancewithcurrentinsulinregimen
Poorcompliancewithprescribedself-blood glucose monitoring
A1cgreaterthan9%
Recurrentseverehypoglycemiarequiringassistanceduringthepast6months
Requiringtheuseofdrugsthatstimulategastrointestinalmotility
Requiringtheuseofdrugsthatslowtheintestinalabsorptionofnutrients
Pediatricpatients
Qualifying Statements
Qualifying Statements
Theseclinicalguidelinesaredesignedtoassistcliniciansbyprovidingananalyticalframeworkfortheevaluation
and treatment of patients and are not intended either to replace a clinician's judgment or to establish a protocol for
all patients with a particular condition. A guideline will rarely establish the only approach to a problem.
l
Thisclinicalguidelineshouldnotbeconstruedasmedicaladviceormedicalopinionrelatedtoanyspecificfactsor
circumstances. Patients are urged to consult a health care professional regarding their own situation and any specific
medical questions they may have.
l
Implementation of the Guideline

Description of Implementation Strategy
Once a guideline is approved for release, a member group can choose to concentrate on the implementation of that
guideline. When four or more groups choose the same guideline to implement and they wish to collaborate with others,
they may form an action group.
In the action group, each medical group sets specific goals they plan to achieve in improving patient care based on the
particular guideline(s). Each medical group shares its experiences and supporting measurement results within the
action group. This sharing facilitates a collaborative learning environment. Action group learnings are also documented
and shared with interested medical groups within the collaborative.
Currently, action groups may focus on one guideline or a set of guidelines such as hypertension, lipid treatment, and
tobacco cessation.
Priority Aims and Suggested Measures
A multifactorial intervention targeting hyperglycemia and cardiovascular risk factors in individuals with diabetes is most
effective. Both individual measures of diabetes care, as well as comprehensive measures of performance on broader
sets of measures, are recommended.
Goals for A1c, low-density lipoprotein and other diabetes measures should be personalized, and lower goals for A1c
and low-density lipoprotein than those included here in the priority aims and measures may be clinically justified in
some adults with type 2 diabetes. However, efforts to achieve lower A1c below 7% may increase risk of mortality,
weight gain, hypoglycemia and other adverse effects in many patients with type 2 diabetes. Therefore, the aims and
measures listed here are selected carefully in the interests of patient safety.
1.Diabetes Optimal Care Measures: Maximize the percentage of adult patients, ages 18-75 with type 2 diabetes
mellitus, who in a defined period of time achieve any of the following measures of established control:
Possible measures for accomplishing this aim:
a.PercentageA1clessthan8%
b.Percentageonastatin
c. Percentagewithlow-density-lipoprotein (LDL) less than 100 mg/dL
d.Percentageoftype2diabetespatientswithbloodpressure(BP)measuredinlastyearandmostrecentBP
less than 130/80 mmHg
e.Percentageoftype2diabetespatientswhoarecurrentdocumentednon-smokers
f. Percentageoftype2diabetespatientsages41to75withtype2diabetesmellitusandwithcoronaryartery
disease (CHD, defined as one or more International Classification of Diseases, Ninth Revision [ICD-9] codes for
CHD listed at ncqa.org) who take daily aspirin or another antiplatelet medication.
2.Diabetes Optimal Care Comprehensive Measure Set: Maximize the percentage of adult patients ages 18 to 75
with type 2 diabetes mellitus, who in a one-year period of time achieve each of the following measures of care.
a.PercentagewithA1clessthan8%
b.PercentagewithLDLlessthan100mg/dL
c. Percentagewithbloodpressuremeasuredinlastyearandmostrecentbloodpressurelessthanorequalto
f. Percentageoftype2diabetespatientsages41to75withtype2diabetesmellitusandwithcoronaryartery
disease (CHD, defined as one or more International Classification of Diseases, Ninth Revision [ICD-9] codes for
CHD listed at ncqa.org) who take daily aspirin or another antiplatelet medication.
2.Diabetes Optimal Care Comprehensive Measure Set: Maximize the percentage of adult patients ages 18 to 75
with type 2 diabetes mellitus, who in a one-year period of time achieve each of the following measures of care.
a.PercentagewithA1clessthan8%
b.PercentagewithLDLlessthan100mg/dL
c. Percentagewithbloodpressuremeasuredinlastyearandmostrecentbloodpressurelessthanorequalto
130/80 mmHg
d.Percentagewhoarecurrentdocumentednon-smokers
3.Diabetes Process of Care Measure Set: Maximize the percentage of adult patients ages 18 to 75 with type 2
diabetes mellitus for whom recommended screening procedures are done.
a.Percentageofpatientswithtype2diabetesmellituswithA1ctestinthelast12months.
b.Percentageofpatientswithtype2diabetesmellitusreceivingalipidprofileinthelast12months.
c. Percentageofpatientswithtype2diabetesmellitusreceivingoneormorebloodpressuremeasurements in
the last 12 months.
d.Nephropathyscreeningrate:DENOMINATOR:Includethosepatientswithtype2diabetesmellituswhoare
either (a) not on an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
medication OR (b) not diagnosed with chronic kidney disease. NUMERATOR: Those who are included in the
denominator who have one or more microalbuminuria tests within the last 12 months. (Suitable tests include
CPT Codes such as 820.43 ["urine, microalbumin, quantitative"], or 841.55 ["protein; total, except
refractometry"]).
e.Retinopathyscreeningrate:percentageofpatientswithtype2diabetesmellituswithdilatedeyeexam
within the last 24 months. The nature of the exam is not specified and may be completed by an
ophthalmologist or optometrist.
f. Footcarescreeningrate:percentageofpatientswithtype2diabetesmellituswithacomprehensivefoot
exam documented in the last year.
g.Diabetes process of care comprehensive measure: percentage of patients with type 2 diabetes, age 18 to
75 with type 2 diabetes mellitus, for whom all the recommended screening procedures (3a to 3f above) were
done in the indicated time frames.
4.High-Risk Population Measures: The purpose of this aim is to identify and focus on a higher risk population by
decreasing the percentage of adult patients, ages 18 to 75 with type 2 diabetes mellitus, with poorly controlled
glucose and cardiovascular risk factors (clinical strategies that target high-risk populations may be more viable with
limited resources).
a.Percentageofpatientswithtype2diabetesmellituswithAlctestinthelastyeargreaterthan9%.
b.Percentageofpatientswithtype2diabetesmellituswithlow-density lipoprotein test in the last year
greater than 130 mm/dL.
c. Percentageofpatientswithtype2diabetesmellituswithbloodpressuregreaterthan140/90mmHg.
d.Percentageofpatientswithtype2diabetesmellituswithA1cgreaterthan9%orlow-density lipoprotein
greater than 130 mg/dL or blood pressure greater than 140/90 mm Hg (high-risk comprehensive measures).
e.Percentageofpatientswithtype2diabetesmellituswhoareactivesmokers.
At this point in development for this guideline, there are no specifications written for possible measures listed above.
Institute for Clinical Systems Improvement (ICSI) will seek input from the medical groups on what measures are of
most use as they implement the guideline. In a future revision of the guideline, measurement specifications may be
included.
Refer to the original guideline document for more information.
Key Implementation Recommendations
The implementation of type 2 diabetes mellitus clinical guidelines at medical groups and clinics is a complex and
challenging task. However, a number of key processes have been shown to accelerate effective clinical guideline
implementation and care improvement. These overlapping care elements can be categorized at the medical group and
provider levels:
l
EssentialElementsattheMedicalGroupLevel:
Leadership. Medical group leaders must communicate the need for change in clinical practice patterns and
consistently identify improvement priorities.
l
Resources. Resources adequate to the task at hand will be needed to assure the success of a change effort.
Resources may include staff time, money and provision of tools (such as electronic medical records) to support care
improvement.
l
Select Specific Improvement Goals and Measures. For most chronic diseases, including diabetes, the most
efficient improvement strategy is to focus on a limited number of specific improvement goals. These may be based
on observed gaps in care, potential clinical impact, cost considerations or other criteria. In type 2 diabetes,
focusing on glycemic control, lipid control and blood pressure control is a strategy that has been shown to be
effective in preventing up to 53% of heart attacks and strokes, the leading drivers of excess mortality and costs in
adults with diabetes.
l
Accountability. Accountability within the medical group is a management responsibility, but external
accountability may also play an important enhancing role to motivate sustained efforts to implement guidelines and
improve care. Examples of external accountability include participation in shared learning activities (such as
Institute for Healthcare Improvement or ICSI and its action groups), or public reporting of results (such as in payfor-performance or the Minnesota Community Measures Project).
l
Prepared Practiced Teams. The medical group may need to foster the development of prepared practice teams
that are designed to meet the many challenges of delivering high-quality chronic disease care.
l
EssentialElementsattheClinicLevel:
effective in preventing up to 53% of heart attacks and strokes, the leading drivers of excess mortality and costs in
adults with diabetes.
Accountability. Accountability within the medical group is a management responsibility, but external
accountability may also play an important enhancing role to motivate sustained efforts to implement guidelines and
improve care. Examples of external accountability include participation in shared learning activities (such as
Institute for Healthcare Improvement or ICSI and its action groups), or public reporting of results (such as in payfor-performance or the Minnesota Community Measures Project).
l
Prepared Practiced Teams. The medical group may need to foster the development of prepared practice teams
that are designed to meet the many challenges of delivering high-quality chronic disease care.
l
EssentialElementsattheClinicLevel:
Develop "Smart" Patient Registries. These are registries that are designed to identify, automatically monitor,
and prioritize patients with diabetes based on their risk, current level of control, and possibly patient readiness-tochange.
l
Assure "Value-Added" Visits. These are office visits or other patient encounters (by phone, e-mail, etc.) that
include intensification of treatment if the patient has not yet reached his/her evidence-based clinical goals. Failure
of providers and patients to intensify treatment when indicated (referred to as "clinical inertia") is a key obstacle to
better diabetes care. Previsit planning and best practice prompts may help to increase the efficiency of patient
visits and remind providers of needed tests and care.
l
Develop "Active Outreach." These are strategies to reach patients with chronic disease who have not returned
for follow-up or for other selected elements of care. Outreach strategies that enhance the likeliness of a future
provider encounter that addresses one of the barriers to patient activation (discussed below) may be more
effective. Simple reporting of lab test results or care suggestions through the mail may be ineffective at addressing
these barriers.
l
Emphasize "Patient Activation" Strategies. These may include diabetes education and other actions designed
to sustain engagement of patients with their diabetes care. Many patients with diabetes either (a) do not really
believe they have diabetes, or (b) do not really believe that diabetes is a serious disease, or (c) lack motivation for
behavioral change, or (d) do not believe that recommended treatments will make a difference to their own
outcomes. For care to be effective, these issues must be addressed for many patients.
l
Implementation Tools
Clinical Algorithm
Pocket Guide/Reference Cards
Quality Measures
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.
Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Identifying Information and Availability

Bibliographic Source(s)
Institute for Clinical Systems Improvement (ICSI). Diagnosis and management of type 2 diabetes mellitus in adults.
Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2009 May. 114 p. [168 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
1996 Mar (revised 2009 May)
Guideline Developer(s)
Institute for Clinical Systems Improvement - Private Nonprofit Organization
Guideline Developer Comment
Organizations participating in the Institute for Clinical Systems Improvement (ICSI): Affiliated Community Medical
Centers, Allina Medical Clinic, Altru Health System, Aspen Medical Group, Avera Health, CentraCare, Columbia Park
Medical Group, Community-University Health Care Center, Dakota Clinic, ENT Specialty Care, Fairview Health Services,
Family HealthServices Minnesota, Family Practice Medical Center, Gateway Family Health Clinic, Gillette Children's
Specialty Healthcare, Grand Itasca Clinic and Hospital, HealthEast Care System, HealthPartners Central Minnesota
Clinics, HealthPartners Medical Group and Clinics, Hutchinson Area Health Care, Hutchinson Medical Center, Lakeview
Clinic, Mayo Clinic, Mercy Hospital and Health Care Center, MeritCare, Mille Lacs Health System, Minnesota
Gastroenterology, Montevideo Clinic, North Clinic, North Memorial Care System, North Suburban Family Physicians,
Northwest Family Physicians, Olmsted Medical Center, Park Nicollet Health Services, Pilot City Health Center, Quello
Clinic, Ridgeview Medical Center, River Falls Medical Clinic, Saint Mary's/Duluth Clinic Health System, St. Paul Heart
Clinic, Sioux Valley Hospitals and Health System, Southside Community Health Services, Stillwater Medical Group,
SuperiorHealth Medical Group, University of Minnesota Physicians, Winona Clinic, Ltd., Winona Health
ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675;
e-mail: icsi.info@icsi.org; Web site: www.icsi.org
Clinics, HealthPartners Medical Group and Clinics, Hutchinson Area Health Care, Hutchinson Medical Center, Lakeview
Clinic, Mayo Clinic, Mercy Hospital and Health Care Center, MeritCare, Mille Lacs Health System, Minnesota
Gastroenterology, Montevideo Clinic, North Clinic, North Memorial Care System, North Suburban Family Physicians,
Northwest Family Physicians, Olmsted Medical Center, Park Nicollet Health Services, Pilot City Health Center, Quello
Clinic, Ridgeview Medical Center, River Falls Medical Clinic, Saint Mary's/Duluth Clinic Health System, St. Paul Heart
Clinic, Sioux Valley Hospitals and Health System, Southside Community Health Services, Stillwater Medical Group,
SuperiorHealth Medical Group, University of Minnesota Physicians, Winona Clinic, Ltd., Winona Health
ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675;
e-mail: icsi.info@icsi.org; Web site: www.icsi.org
Source(s) of Funding
The following Minnesota health plans provide direct financial support: Blue Cross and Blue Shield of Minnesota,
HealthPartners, Medica, Metropolitan Health Plan, PreferredOne, and UCare Minnesota. In-kind support is provided by
the Institute for Clinical Systems Improvement's (ICSI) members.
Guideline Committee
Committee on Evidence-Based Practice
Composition of Group That Authored the Guideline
Work Group Members: Bruce Redmon, MD (Work Group Leader) (University of Minnesota) (Division of Endocrinology);
JoAnn Sperl-Hillen, MD (Work Group Leader) (HealthPartners Medical Group) (Internal Medicine); Richard Bergenstal, MD
(Park Nicollet) (Endocrinology); Steve Smith, MD (Mayo Clinic) (Endocrinology); Greg Frane, MD (Northwest Family
Physicians) (Family Medicine); Patrick O'Connor, MD (HealthPartners Medical Group) (Family Medicine); Todd Wade, MD
(Mayo Clinic) (Family Medicine); Julie Roberts, MS, RD, CDE (HealthPartners Medical Group) (Health Education); Eugene
Ollila, MD (Allina Medical Clinic) (Internal Medicine); Penny Louise Flavin, APRN (Olmsted Medical Center) (Nursing);
Carol Manchester, MSN, APRN (Fairview Health Services) (Nursing); Sarah Merbach, BS, RPh (Olmsted Medical Center)
(Pharmacy); Vyvy Vo, PharmD (HealthPartners Medical Group) (Pharmacy); Melissa Marshall, MBA (Institute for Clinical
Systems Improvement) (Facilitator)
Financial Disclosures/Conflicts of Interest
ICSI has adopted a policy of transparency, disclosing potential conflict and competing interests of all individuals who
participate in the development, revision and approval of ICSI documents (guidelines, order sets and protocols). This
applies to all work groups (guidelines, order sets and protocols) and committees (Committee on Evidence -Based
Practice, Cardiovascular Steering Committee, Women's Health Steering Committee, Preventive & Health Maintenance
Steering Committee and Respiratory Steering Committee).
Participants must disclose any potential conflict and competing interests they or their dependents (spouse, dependent
children, or others claimed as dependents) may have with any organization with commercial, proprietary, or political
interests relevant to the topics covered by ICSI documents. Such disclosures will be shared with all individuals who
prepare, review and approve ICSI documents.
Richard Bergenstal, MD has stock in Merck through a family inheritance. Dr. Bergenstal participates in clinical research
and/or serves on a scientific advisory board for Amylin, Merck, Pfizer, ResMed, Valeritas, Eli Lilly, Novo Nordisk, SanofiAventis, MannKind, Intuity, Roche, LifeScan, Abbott, Bayer and Medtronic. All compensation goes directly to the nonprofitParkNicolletInstitute.Dr.BergenstalisanofficerwithintheAmericanDiabetesAssociation.
Carol Manchester, MSN, APRN received speakers' fees or honorarium from Sanofi-Aventis and Pfizer.
Patrick O'Connor, MD receives research or grant funding from HealthPartners Research Foundation; National Institute of
Diabetes and Digestive and Kidney Diseases; National Institute for Health; National Heart, Lung, and Blood Institute;
Robert Wood Johnson Foundation, Agency for Healthcare Research and Quality; Centers for Disease Control; Minnesota
Department of Health, University of Minnesota. Dr. O'Connor received speakers' fees or honorarium from Merck.
Bruce Redmon, MD is contracted with Ingenix and receives research or grant funds from Mannkind Corp.
Steve Smith, MD is a member of the national board of directors for the American Diabetes Association.
JoAnn Sperl-Hillen, MD receives research support from National Heart, Lung, and Blood Institute; National Institute of
Diabetes and Digestive and Kidney Diseases; and Merck.
No other work group members have potential conflicts of interest to disclose.
ICSI's conflict of interest policy and procedures are available for review on ICSI's website at www.icsi.org
Guideline Status
summary.
Guideline Availability
Electronic copies of the updated guideline: Available from the Institute for Clinical Systems Improvement (ICSI) Web
site
Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 8147060; fax, (952) 858-9675; Web site: www.icsi.org
; e-mail: icsi.info@icsi.org.
Availability of Companion Documents

The following are available:
Diagnosisandmanagementoftype2diabetesmellitusinadults.Executivesummary.Bloomington(MN):
Institute for Clinical Systems Improvement, 2009 May. 2 p. Electronic copies: Available from the Institute for Clinical
l
Systems Improvement (ICSI) Web site

l
ICSIpocketguidelines.May2007edition.Bloomington(MN):InstituteforClinicalSystemsImprovement,2007.
7060; fax, (952) 858-9675; Web site: www.icsi.org
Availability of Companion Documents

The following are available:
Diagnosisandmanagementoftype2diabetesmellitusinadults.Executivesummary.Bloomington(MN):
Institute for Clinical Systems Improvement, 2009 May. 2 p. Electronic copies: Available from the Institute for Clinical
l
Systems Improvement (ICSI) Web site

l
ICSIpocketguidelines.May2007edition.Bloomington(MN):InstituteforClinicalSystemsImprovement,2007.
Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 8147060; fax, (952) 858-9675; Web site: www.icsi.org
Inaddition,aformondiabeticfootscreeningisavailableintheappendicesoftheoriginalguidelinedocument.
Patient Resources
None available
NGC Status
This summary was completed by ECRI on June 30, 1999. The information was verified by the guideline developer on
August 4, 1999. This summary was updated by ECRI on October 13, 2000 and May 7, 2002. The summary was most
recently updated on March 14, 2003. The updated information was verified by the guideline developer on May 15, 2003.
This summary was updated again by ECRI on July 8, 2004, January 25, 2005, December 30, 2005, and December 18,
2009. This summary was updated by ECRI Institute on May 17, 2010 following the U.S. Food and Drug Administration
advisory on Plavix (clopidogrel).
Copyright Statement
This NGC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Guideline) is based on the original
guideline, which is subject to the guideline developer's copyright restrictions.
The abstracted ICSI Guidelines contained in this Web site may be downloaded by any individual or organization. If the
abstracted ICSI Guidelines are downloaded by an individual, the individual may not distribute copies to third parties.
If the abstracted ICSI Guidelines are downloaded by an organization, copies may be distributed to the organization's
employees but may not be distributed outside of the organization without the prior written consent of the Institute for
Clinical Systems Improvement, Inc.
All other copyright rights in the abstracted ICSI Guidelines are reserved by the Institute for Clinical Systems
Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or
revisions or modifications made to the abstracts of the ICSI Guidelines.
Disclaimer
NGC Disclaimer
TheNationalGuidelineClearinghouse(NGC)doesnotdevelop,produce,approve,orendorsetheguidelines
represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty
societies, relevant professional associations, public or private organizations, other government agencies, health care
organizations or plans, and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to
determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusioncriteria.aspx.
NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or
effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and
opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of
NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for
advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.

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Guideline Summary NGC-7360

: The U.S. Food and Drug Administration (FDA) notified healthcare

Bloodpressurecontrol,includingangiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor

Population-based descriptive study

Population-based descriptive study

Methods Used to Analyze the Evidence

Focusoncardiovascularriskreduction(bloodpressurecontrol,low-density lipoprotein cholesterol control and

Initialtherapywithlifestyletreatmentandmetforminisadvisedunlesscontraindicated. (Annotations #4, 10)

Diagnosis and Management of Type 2 Diabetes Mellitus Algorithm Annotations

Initialtherapywithlifestyletreatmentandmetforminisadvisedunlesscontraindicated. (Annotations #4, 10)

Diagnosis and Management of Type 2 Diabetes Mellitus Algorithm Annotations

Currentmedicationsincludingover-the-counter medications, dietary supplements and alternative therapies

Physical Examination [R]

Glycosylatedhemoglobin(A 1c ) (not required for prediabetes)

Fastinglipidprofile:totalcholesterol,high-density lipoprotein (HDL cholesterol) low-density lipoprotein (LDL)

Oralglucosetolerancetest2-hour plasma glucose: 140 mg/dL to 199 mg/dL

Oralglucosetolerancetest2-hour plasma glucose: 140 mg/dL to 199 mg/dL

Patients who respond to lifestyle interventions:

Annualfollow-up and reassessment of risks for developing diabetes [A], [R]

5.Diagnosis of Type 2 Diabetes

6.Should Patient Be Hospitalized?

Uncontrolledinsulin-requiring diabetes during pregnancy

Surgery,infection,steroids if these conditions cause significant hyperglycemia and rapid initiation of

7.Inpatient Diabetes Management

Surgery,infection,steroids if these conditions cause significant hyperglycemia and rapid initiation of

7.Inpatient Diabetes Management

Other considerations include [R]:

Insulin therapy may not be permanent once patient is stabilized.

Athirdexampleistocalculatethetotaldailydoseofinsulinat0.3units/kgandusepre-mixed insulin with

Boththequantityandthetypeorsourceofcarbohydrateinfoodinfluencespost-prandial glucose levels.

Sucrose(e.g.,tablesugar)andsucrose-containing foods do not need to be restricted. However, they should

Encourageconsumingawidevarietyoffiber-containing foods such as legumes, fiber-rich cereals, fruits,

PatientswithelevatedcholesterolandLDL-cholesterol: implement National Cholesterol Education Program

Medical Evaluation to Assess Safety of Exercise Program

Physical activity can be intermittent or cumulative [A], [R].

Physical activity can be intermittent or cumulative [A], [R].

Avoidinjuriesfromcuttingtoenailsavoidself-cutting calluses or corns.

Extensivecomorbidconditionssuchasrenalfailure,liverfailureandend-stage disease complications

Consider Statin, unless Contraindicated

Online calculator: http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof

Aspirin/Antiplatelet Medication Optional [A]

Goals for Tobacco Use - Smoking Cessation, if Indicated

Practicalcounseling(problem-solving/skills training and social support delivered as part of the treatment)

Consider Statin, unless Contraindicated

LDL Less Than 70 mg/dL

Three pathways to improve lipids are:

Aspirin/Antiplatelet Medication Use unless Contraindicated [A]

Prevention and Management of Obesity (Mature Adolescents and Adults)

Hypertension Diagnosis and Treatment

Lipid Management in Adults

Major Depression In Adults in Primary Care

See the Glycemic Control and Blood Pressure Control Algorithms

Diabetes Care Team

PleasenotetheworkgroupleftthebrandnamesforHumalogand Novologin the table (see the original

Therearerarecross-sensitivities for patients with sulfa allergies.

Alpha Glucosidase Inhibitors

Therearerarecross-sensitivities for patients with sulfa allergies.

Alpha Glucosidase Inhibitors

Dipeptidyl Peptidase-4 (DPP-4) Inhibitor

SevereandESRD(start25mgoncedaily):CrCl<30mL/min:serumcreatininelevels[mg/dL]-- men: >3.0;

Therearenoadequateandwell-controlled studies in pregnant women.